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

A 3-point plan to save the National Care Service – before it’s too late – Gordon Hector

It’s official: plans for a National Care Service are in trouble. Yesterday Alex Neil said it should be scrapped. That followed fellow SNP MSPs calling it a ‘blank cheque’. The Fraser of Allander InstituteCoslaunions,  NHS leaders – and of course Reform Scotland – have all voiced concerns.

This is more than just the usual chuntering. This is the backbone of Scotland’s public sector saying: stop.

It creates a nightmare scenario for the Scottish Government. It still has the votes to pass its bill, and it would be hugely embarrassing to drop it. And there is a strong case for change. But there will be a big, loud argument as it comes into being – big and loud enough to destabilise the care system. If that happens, then right at exact moment Ministers start taking responsibility for the whole thing, it might just fall over.

So Humza Yousaf is in a bit of a pickle. If he presses ahead, the system might collapse. And he probably ends his career.

But if he completely abandons the plan, the system loses the moment to make a change. And he probably ends his career.

What should the Scottish Government do? I’d suggest three things to get an NCS over the line by the next election, but in better shape, and without blowing the whole system up.

Make it a single process

 First – the Scottish Government should make it a single process.

The National Care Service Bill is going through the Scottish Parliament. Separately, a big policy ‘co-design’ process with the sector is playing out.

This twin-track approach is good in theory: it makes sense to keep legislation focused, and engage broadly.

The problem is trying to do both at the same time. MSPs feel like they don’t have the full picture, because many big choices simply aren’t in the Bill. Experts like the FAI get frustrated they can’t properly cost it, and that ‘there will be relatively less opportunity for scrutiny than would be the case if a fuller set of NCS reforms had been ready for inclusion in primary legislation.’

At the same time, there is chatter that some of the co-design sessions are peppered with caveats that decisions are ‘subject to parliamentary scrutiny’. That doesn’t exactly breed confidence.

Ministers should align the two processes, so it goes 1) co-design and then 2) a Bill to enact the design. That would build trust, make it easier to communicate, and keep the policy coherent. It probably adds 6-18 months to the bill. That is better than losing control.

So that’s point one: process. But opposition is also driven by substance. So my second act would be a substantial change: back down on taking care services away from local authorities.

Back down on removing local authorities

 Why? Because this is the bit of the proposal which has by far the most political, financial and operational risk.

Political risk, because this is the kernel of opposition from Cosla, unions and bits of the NHS, and MSPs of multiple parties.  

Operational risk, because this is the change which has the potential to send care into meltdown. Ministers can talk breezily about ‘shifting commissioning from local authorities to the NCS’ but what many staff will hear is ‘my job is at risk’. They might start walking, with a ripple effect across the whole sector. We are already in a staffing crisis: structural reform in that context is an enormous gamble.

And financial risk, because it creates all sorts of questions around the cost processes switching over, contracts needing reviewed, harmonising pay, the risk of rising agency spend, and more. This is why the NCS feels like a blank cheque. If you switch responsibilities from councils to care boards, you just cannot assume that it costs the same.

These risks are in themselves good reasons to rethink. But there is another bonus: which is that the local-national switch probably isn’t going to achieve what Ministers want anyway. It takes about 30 seconds looking at the NHS, or ScotRail, or our ferry network, to realise that it just isn’t as simple as Ministers taking accountability, and therefore services improving. It just isn’t how complex systems work. We’ve spent 60 years re-learning this lesson. You need to find ways to hedge against the tendency of bureaucracies to turn inwards and become accountable only to themselves. Known methods include keeping diversity of provision, creating strong incentives to respond to user needs, and keeping leadership with a deep connection to places – all of which are represented in the current system.

So changing this bit of the plan reduces the political, financial, and operational risks, as well as removing the bit most likely to underwhelm.

But doesn’t this just keep the system very patchy? Isn’t this just a massive u-turn? Does it even mean that we’d have a ‘national’ care service at all?

This is where the third suggestion would come in. Ministers should go slower on removing local control. But if they do that, the path is clear to go further on creating a new central function, in one specific regard.

Creating central improvement

 The NCS itself isn’t an organisation. It’s more an umbrella term for a series of organisations, mostly care boards, and in future ‘special boards’ reporting to ministers.

A consultation last year proposed a National Social Work Agency as a new central body, but since then it’s gone a bit quiet.

This creates a gap, and an opportunity. This is to accelerate the Agency, or something like it, and go much further and faster in creating a central improvement body. Improvement organisations deploy combinations of incentives, training, culture-change, communications and research to define standards, unlock innovation, and improve services. There are three reasons to think one would work. 

First, improvement is not new. The patient safety programme is our best home-grown example of its potentially transformative effects. Elsewhere in the UK, organisations like Social Work England are heading in this direction.

Second, what is new is the advance of digital technology and data. This is taking improvement from being a bit touchy-feely into a much more robust public service profession in its own right, devoted to creating feedback loops of data, measurement and user-centricity. Technology creates lots of questions, ranging from the practical (social care data is often weak) to the ethical (we don’t want to commoditise care) – so there’s a lot to think about. But this is still a moment of immense potential for a new improvement organization that understands technology and the role it can play in driving quality.

And finally, the Care Boards look likely to be good at caution and meetings, and bad at driving change. This is because they are a Board, and most Boards end up this way. Particularly ones where everyone knows each other already.

If we really want to do something new, then we should build something new. Build a new organisation working from the centre, roving around the rest of the system as a cheerleader, champion and coach. Build it small, nimble, and impatient with mediocrity.

This would be a new national institution trying to create a nationwide ethos but it would be working with local provision, not try to displace it. That makes it quite different from simply creating a national structure of Boards: it does still encourage the kind of consistency and quality and common identity which the NCS is supposed to achieve, but working with locally-responsive providers. Politically, it means Ministers would still get to claim, in all good faith, that they have created a national care service. It’s just swapping the mechanism from a centrally-led NHS-style structure, to a supercharged central improvement agency working with locally-led systems.

Not a u-turn, just a detour

 That’s my three-part grand bargain: align the parliament and policy timelines; ditch the centralisation of provision; but put more emphasis behind centrally-led improvement.

Maybe this sounds a bit like gutting the bill and moving very slowly. But then that is how we got the NHS: the NHS in Scotland was not invented overnight in 1948 but was built on 19th-century medical schools, the 1920s Highlands and Islands Medical Service, the 1930s Cathcart report, and 1940s wartime emergency services. If Ministers really do want the NCS to be like the NHS, there is really no shame in building it gradually.

I don’t think we’ll ever need to do that. My view is that a regulated system of diverse provision is more likely to work than a vast pyramid run from the top. But the beauty of being cautious for now is that it preserves options. If I’m wrong, then we can still create a bigger NCS superstructure in future.

This need not be a u-turn: more of a scenic route.

Put it all together and I think there is a package which takes the heat out of the process, brings civic Scotland along for the journey, preserves options for the future, and still gets you the ‘we did an NCS’ boast on a pledge card in 2026.

Above all else, it won’t ruin the system as it’s introduced. And if it preserves care, it will probably preserve a few careers too.

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