Learning from social care: Citizen choice & budgetary control in NHS 2048 – Donald Macaskill

2048 is of course the 100th anniversary of the founding of the NHS but during this past years’ 75^th NHS celebrations you might have missed the other 75^th birthday – that of modern social care. I don’t think we even got a slice of the birthday cake!

Reform of the NHS in Scotland is urgent and necessary, and I cannot but agree with Paul Gray’s summons to the robust and thoughtful decision-making of choice. There is a requirement both to think outside the box and to think the unthinkable in the exploration of necessary change.

However, any attempt to address the challenges and more importantly shape the potential of health provision in Scotland will be for naught unless the symbiotic relationship with social care is both recognised and prioritised.

My reading of the writings and speeches of Aneurin Bevan and the others who founded the NHS has always led me to the conclusion that they saw the role of community-based care and support (in the non-clinical sense) as intrinsic to the welfare and wellbeing of communities. He even extended some of this thinking to social housing portraying a model of social wellbeing which was ahead of its time with its recognition that good health was more than the absence of disease.  Sadly, for many reasons we have lost that holistic vision which rooted wellbeing in community, as increasingly the NHS has become the National Hospital Service. A misplaced emphasis on acute and secondary healthcare has been at the expense (quite literally) of both primary and social care. Moving towards 2048 we urgently need to find afresh that balance and to re-discover the social dimension of health and care.

Social care is not about maintaining our population as they are, but rather it is about the enabling of citizens to thrive and flourish to the fulness of their lives regardless of age, disability, or circumstance. Social care is about independence, control, choice, and voice. These are not empty words but are themselves reflective of the social and communitarian dimension of social care which the Social Work (Scotland) Act of 1968 emphasises. It underscored the criticality of supporting people in community, as social and ‘independent’ beings with relationships which are as a significant for wellbeing as any medical procedure. An emphasis on ‘choice’ recognises the importance of avoiding a one size fits all approach to social care and instead enables a diversity of provision that fits the distinctive and peculiar needs of folk. And ‘voice’ is about giving real control and power to the citizen not playing lip service to engagement and involvement. The professional being on tap not on top. The system being there to serve rather than to become an end in itself.

The fact is the worlds of the NHS and social care in contemporary Scotland are vastly different and we ill-serve either by failing to recognise, celebrate and value that diversity. Yet over the decades what has happened is that we have negatively created a divide because of the inequality of treatment for social care, its workforce and its resourcing. Social care truly is the Cinderella service where it should be a joint partner with the NHS in the embedding of social health and care in the community.

I think there are two aspects of contemporary social care that might contribute to the shaping of the NHS in 2048 if we allow it.

The first is an emphasis upon preventative and autonomous care and support. Citizens are increasingly in control of so much of their lives through the digital and technological revolutions we are living through, accelerated by the potential of AI. The use of home-based technology (being careful to avoid social and access inequalities) offers us a real prospect for shaping care to distinctive needs, for radically reducing avoidable and unnecessary acute hospital admissions, for preventing the huge human and fiscal costs caused by frailty and falls, and for treating and supporting people for longer in their own homes or a homely setting. The NHS 2048 needs to be tied into this revolution of autonomy and prevention.

The second is the need to maximise fiscal autonomy on the part of citizens as they access health and care. Despite resistance and vested interest from some parts of the public sector the principles in practice of the Social Care (Self-directed Support) (Scotland) Act 2013 continue to champion the rights of citizens to be given a social care budget and to spend it in shaping and selecting the care support that best fits their needs and aspirations. Social care at its optimum treats the citizen as a grown up rather than the plaything of public sector parents too frightened of the loss of power to cut the fiscal and control apron-strings. But it requires real choice and real options and therefore a managed social care market that reflects the modernity of divergent requirements that people are increasingly demanding. Is it heresy to say that the NHS can learn some of the lessons which result when we authentically empower the patient through real choice including by offering greater financial control for their healthcare (and I am not saying removing the principle of ‘free at the point of need’)? We know that citizens who are given choice exercise that to the maturity of their health and to the benefit of the wider health economy – why don’t we give choice, voice, control and budgets to our patients?

Let’s be bold and imaginative because 25 years is simply not a long period of time and unless we do so we might not reach our joint NHS and social care 100^th when hopefully there will be one cake shared amongst all.

Dr Donald Macaskill is the Chief Executive of Scottish Care.

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