There is a strong majority in the Scottish Parliament for the creation of a National Care Service in Scotland and the Scottish Government has previously indicated that it will be built along the model set out in a review it commissioned after the care home tragedy during Covid.
So does this mean that Scotland is truly on the cusp of a revolutionary and (this time genuinely) world-leading change in how it manages care services? At the moment there is strong reason to doubt that – but some hope it might change.
In the aftermath of the worst of the Covid deaths in care homes during the pandemic the First Minister announced and set up a review of the provision of adult care services. She appointed Derek Feely to undertake this review.
There was much about this which raised not unreasonable alarm bells. While prior experience of public care policy clearly doesn’t exclude someone from leading this review, Derek Feely was for years the most senior civil servant responsible for care policy (before a stint in the United States and its privatised health system). It was hard not to feel like this was ‘insiders marking their own homework’ and bringing ‘more lessons from America’.
Those fears were not allayed by the timescales and methodologies. The Review was announced in September 2020, effectively began work on 30 September but stopped taking evidence on 6 November and finished work entirely by the end of January 2021.
The engagement involved ‘a series of digital engagement events’, facilitated by the Health and Social Care Alliance Scotland which is dependent on the Scottish Government for funding, and a ‘facilitation pack’. Effectively, organisations without vested interests in the current system had a couple of weeks to examine the questions, get together their ideas, write them down and submit them and a series of ‘chat session’ were held online.
A three-month beginning-to-end process for creating a National Care Service (with barely any serious opportunity for anyone external to the Review to put ideas together in a coherent way) is not sufficient for producing a plan of the scale implied.
All those concerns about the process were largely borne out by the final report. First, it was presented (and celebrated by the Cabinet Secretary for Health) as a National Care Service. But it excluded very much more than it included – children’s services, mental health services, drug support services…
An insider-dominated process which was barely fit for purpose ignored most of the care services that exist in Scotland and produced a proposal which primarily rebranded existing practice
Second, it failed to address the problems which had led to the tragedy in our care homes and simply dismissed the idea of a ‘publicly-owned’ NCS and then recommended that the same provision would be commissioned from the same providers with a few minor tweaks. Care would continue to be dominated by private interests.
Other aspects central to the National Health Service like collective bargaining for staff were also largely ruled out. Resource issues were for the best part dodged – it recognised resource constraints but little more. Strangely it simply omitted any critical consideration of the current policy of health and care integration, and in a number of other ways it simply avoided big issues.
But it did propose one significant change; centralisation. Rather than being delivered locally by local authorities care would be centralised in a national agency responsible directly to the Scottish Government. It is this which is causing the very substantial hostility from local authorities.
In effect, an insider-dominated process which was barely fit for purpose ignored most of the care services that exist in Scotland and produced a proposal which primarily rebranded existing practice but made it ‘national’ by removing local control and handing direct control to a Scottish Government minister. That is the same Scottish Ministers who were responsible for the disastrous mishandling of the care home crisis last year.
If this system was put side-by-side with the National Health Service, few would claim they were comparable in any meaningful way. If the NHS was to be transformed to be more like the NCS it would be largely privatised, resources would be withdrawn, the workforce casualised and a majority of medical procedures and healthcare practices would be removed. It seems difficult to argue that this is anything like a National Care Service.
But this does at least seem to be recognised by the team now taking the proposals forward. The latest consultation document runs to 140 pages and does acknowledge that the need for care runs through our lives and a National Care Service should be about more than care provision for those who are reaching the end of the lives
Still, there remains plenty of concerns. Although 140 pages long, many questions in the consultation are extremely specific while there are entire thematic areas where it is difficult to understand how the Scottish Government envisages what a National Care Service should actually be in practice while the question of resources is ignored. The concern remains that this is an insider-focussed process.
This is a worry; care in Scotland is dominated by vested interests and if they are able to carve-up a National Care Service between them, the likelihood appears to be that the existing system will replicate itself again, but with new branding.