Caring For All: A National Care Service For Scotland

― Care is the reciprocal, relationship-based underpinning of all of human society. The vast majority of care is informal or social, but sometimes social failure or acute conditions creates caring needs that cannot be met informally. The purpose of a National Care Service (NCS) should be to meet those needs.

― Creating a NCS will require significant investment but will have major social benefits and will, over time, help reduce the cost that the public sector pays to deal with social failures.

― The scale of unmet care is not well measured but it is very large – possibly as many as one in five people need care support of some kind but about 90% of them receive no formal care at all.

― Care services are currently in a critical state and not fit for purpose:- underfunded, rationed, fragmented, centralised, top-down and risk averse. Staff are undertrained and underpaid, morale is low and turnover high.

― The NCS should be built on a firm foundation of effective social work practice, but social work has had its budget slashed and has been broken up and fragmented.

― In Scotland care is driven not by what works but by what politicians think works, with no meaningful response from government to people’s experience of the system or the academic study of what really works, and largely disregarding the knowledge and expertise of professionals.

― Care provision works when it is based on sustained, trusting relationships, is focussed on prevention rather than ‘protection’ and is about supporting people not enforcing rules. The top-down managerialism of the Scottish system means care professionals are not trusted to work together with people to work out what they need.

― Human rights is an important framework for care but is insufficient without adequate resources, a clear line of responsibility for ensuring rights are met and the effective relationships which enable care. Rights, Resources, Responsibilities and Relationships are ‘the Four Rs’ on which care should be built.

― This enables a set of fundamental guiding principles to be created:

Care must be universal and must always promote welfare;
Care must be easily accessible to prevent problems worsening;
Services should be built on relationships with minimum intervention and minimum bureaucracy;
Care should be based on a shared, collective agreement on needs and outcomes;
Independent living, within a network of interdependent relationships, should normally be the goal;
Provision should be public and free at the point of need;
The workforce must be valued and rewarded;
and Diversity and difference must be recognised – of care needs and of different communities.

― Just as we recognise the difference between healthcare and ‘public health’ (the promotion of a society which reduces the need for medical intervention) so we need the concept of ‘public care’ – the promotion of what creates a caring society and which reduces the need for formal care.

― The vast majority of care is informal and we must support informal carers – there are about three quarters of a million informal carers in Scotland (not including a million parents with dependent children).

― For care needs not met by a ‘public care’ approach or through supporting informal carers we need a comprehensive, all-ages NCS ‘from womb to tomb’.

― The NCS will provide consistent care support from conception (where prospective parents will be given support and training if they want it) through to elderly care at the end of life – and anything in between, from addiction issues to incapacity to housing needs to psychological services.

― The NCS must be easy to access. Just as, in most instances, the GP’s surgery is the first port of call for people with health needs, so we must establish Local Care Hubs as the first port of call (and the organising centre) for care needs.

― A Local Care Hub must be designed to minimise stigma – for example, accessible, there for all, co-located with other community services and facilities. This will be helped by creating the kind of long-term, consistent relationship people have with their GP practice.

― A Local Care Hub should bring together all sorts of care-related services such as Citizens’ Advice Bureaux, local authority housing officers and credit union or community banking services.

― There should also be a 24-hour national phone line for emergency care issues (like NHS 24) and emergency response services to people’s houses.

― People with problems which cannot be dealt with on the spot by the Local Care Hub would be referred on to other (specialist) services and those referrals would be primarily local.

― Care provision should be organised locally as local conditions and resources (housing, community infrastructure, childcare provision, schools) are central to successfully achieving good care outcomes – and are the responsibility of local government.

― The NCS should therefore be delivered in communities, coordinated by the local authority but funded centrally to ensure accountability, and with a specific government minister at Cabinet level designated to carry responsibility. The responsibilities which would be carried out at the national level would be strategic; data collection, workforce planning, pay and conditions, procurement and so on.

― Staff need to be trusted and empowered, and bureaucracy minimised (such as the example of an English local authority which replaced a mountain of bureaucracy with the single simple sentence “Don’t break the law; Don’t blow the budget; Do no harm”).

― ‘Choice’ is a badly-flawed means of deciding care provision, every bit as much as if the NHS was expected to deliver precisely what patients wanted without reference to a professional assessment of need. There will inevitably be compromises in care as resources will never be unlimited but the best way to manage this is for local teams to negotiate with local communities and those they deliver care to (‘Ethical Commissioning’) while recording unmet need to inform future care provision. These negotiations cannot be done centrally.

― To make this work the two primary barriers to receiving care must be removed – eligibility criteria (used to ‘ration’ care) and charging (acting as a ‘paywall’ to care). It should be left to the judgement of care teams working with those with care needs to identify priorities where resources are limited.

― For this to happen staff must be trained and paid at a level which enables them to take ethical decisions where care needs conflict and deliver a consistent, high-quality service. National collective bargaining is required to address pay issues, with trade unions driving negotiations, and proper training put in place for staff, both prior to starting work and then to support continued professional development.

― From there, staff must have sufficient time with each person they are caring for and the power to decide with them the best way to meet their care needs while assured that management is supporting them, not policing them.

― A NCS must be a not-for-profit services exactly like the NHS. The profit motive works against all of the above.

― This can be achieved in three steps: letting any low-profit private and voluntary providers come in under the NCS, nationalising any community based provision which isn’t physical asset-based and gradually investing in more localised provision, signalling that for-profit commissioning will cease (this may involve some direct acquisition of property which is already being paid for from public budgets).

― Care and health are closely linked, but one is not a subset of the other – which is why the integration of health and care is failing, driven as it is by managerial interests. Each service has a different focus and different practices and so should be stand-alone; the role of managers is to ensure that frontline staff in each service can effectively ‘talk to’ the other (for example ensuring consistent IT approaches in both services).

― The regulation of care is a mess and needs serious reform. It must return to a focus on professional enhancement and development and not an assumption it is policing the actions of care workers. The two existing regulatory bodies should be amalgamated and sit inside the NCS at the national level. Much of the regulatory framework is in place to deal with the free market component of current care arrangements and so would become redundant.

― Instead, there should be a process of ‘reflective practice’ in which workers are supported by their peers and managers to ensure quality provision on a mutual basis – with the power of the regulator to intervene increased in the cases where reflective practice at the individual or service level fails.

― While fully funding a new NCS will be challenging, the current level of resources make a real NCS impossible. As well as the additional £800m the Scottish Government has decided to invest in care the £1 billion of ‘Barnett Consequentials’ which are expected to come to Scotland as a result of the increase in National Insurance contributions is sufficient to make a very good start to the reforms we have outlined.

― This is the minimum of what it should be acceptable to call a ‘National Care Service’ and Scotland must not accept anything less than this level of ambition.