Chapter 5 The case for a national care service (NCS)
"We need a system that is controlled nationally, that delivers locally, has the person at the centre, that does not cost the earth”
The Terms of Reference for this review make no reference to a National Care Service, although the First Minister in her Programme for Government announcement set out her ambitions to build out of the Covid-19 pandemic a social care legacy equal in stature and impact to the creation of the National Health Service after World War 2:
". . . the pandemic has reminded us of the vital importance of social care services, and of the extraordinary professionalism, dedication and compassion of those who work in that sector. However, it has also underlined the need for improvement and reform. I can therefore announce today the immediate establishment of a comprehensive independent review of adult social care. The review will seek the views of those with direct experience of adult social care, and make recommendations for immediate improvements. However, more fundamentally, it will examine and set out options for the creation of a National Care Service. . . The quality of adult social care is something that matters deeply to us all. This is a moment to be bold and to build a service fit for the future. The National Health Service was born out of the tragedy of World War 2. Let us resolve that we will build out of this COVID crisis, the lasting and positive legacy of a high quality, National Care Service for all who need it."
Nicola Sturgeon MSP, First Minister
1 September 2020
During the engagement phase of our review many people asked what a National Care Service would consist of, how it would be organised and who would pay for it. When we asked people for their suggestions, many different ideas were shared. Some people were strongly in favour, others strongly opposed, and others were not sure without more details.
The pandemic has demonstrated clearly that the Scottish public expect national accountability for adult social care support and look to Scottish Ministers to provide that accountability. Statutory responsibility for care homes sits with Local Authorities and individual providers. However, it was clear during the pandemic there was an expectation that Scottish Ministers should be held to account, which makes sense from a public health perspective. We therefore recommend the establishment of a National Care Service – that brings together all adult social care support delivered in Scotland.
We recognise that Ministers do not currently hold the levers that would enable them to manage the social care support services for which they are held to account. We nevertheless think the expectation of Ministerial accountability is reasonable, in light of adult social care support's impact on people's wellbeing, its deep links to and mutual dependency with the National Health Service, and the scale of public funding for it.
We also recognise that Local Authorities have a key statutory role to play in supporting public wellbeing that is wider than provision of social care support, extending to for instance housing, transport and, leisure and recreation. We believe that, by establishing national accountability for adult social care, the Scottish Government can work with local systems to address systemic problems evident in our current arrangements while at the same time developing, maintaining and enriching key links to other Local Authority services. We envisage an important and continuing role for Local Authorities as public providers of social work and social care services, and as partners in Integration Joint Boards, where they will continue to work with their NHS partners and others to meet local needs and steward health and social care resources.
A National Care Service must ensure that people have equity of access to social care supports, and experience a similarly high quality of care, wherever they live in Scotland. Where there is variation in the kinds of care provided in different parts of the country, that should be a positive response to differences in geography, local assets and local priorities. There should not be inexplicable or un-evidenced variation in care that diminishes or harms people's life experiences. There should be a consistent, national focus on preventative, early intervention and anticipatory forms of support that shift the emphasis, and experience of care, away from crisis intervention and towards better quality of life. Lower level needs should not be left unattended until they become a bigger problem, they should be addressed to avoid the bigger problem occurring.
As identified in Chapter 3, care and support should be portable. When someone has been assessed for care in one part of the country they should be able to move to another area and take their entitlement to social care support with them. The current situation, which requires people to be re-assessed for support in their new home, impinges directly on their rights to lead a socially engaged, full and active life, and is wasteful and bureaucratic.
Some aspects of adult social care support need new and modified arrangements at national level to support the progress required.
New provision should be made for learning and improvement programmes for social work and social care, to support quality, improvement, consistency, professionalism and to work directly with equivalent provision in the NHS. There is a pressing need for a national infrastructure to scale-up and spread promising local practice as well as to deal consistently with common challenges. These arrangements must focus on the skillsets specific to social work and social care support and links to equivalent developments of the health workforce. The Scottish Social Services Council (SSSC) and NHS National Education Services Scotland (NHS NES) linking effectively to Scottish Universities and Colleges, should be part of the new arrangements and must work much more closely together to build upon each other's strengths. Neither organisation is currently fully equipped to provide the scale and range of support required to improve the quality of social care support or deliver effective integration.
Provision should also be made at national level for support for people whose needs are very complex or highly specialist. This will provide people with greater levels of support and allow for the cost to be absorbed nationally. The Independent Living Fund Scotland should form part of the suite of services supported at national rather than local level and become part of the National Care Service. We consider in Chapter 11 whether the Independent Living Fund should be reopened with additional investment.
Consideration should also be given to supporting social care in prisons and other custodial settings as part of the national service rather than through local arrangements.
We believe that the problems outlined above can only be dealt with by a National Care Service that drives forward improvement and requires certain common standards and rights based approaches across Scotland. We therefore recommend that the accountability of Scottish Ministers for adult social care support should be legally established to put beyond doubt that overall responsibility sits with the Scottish Government. This will mean that Local Authorities are no longer legally accountable for adult social care support. Of course, as key partners in Integration Joint Boards, they will continue to influence and direct resources to meet identified local needs and they will provide social care support and professional social work services.
We also recommend that, recognising this shift in responsibility, a Minister for Social Care should be appointed.
Statutory responsibility for adult social care support should be set out in law along similar lines to those already established for health services, to establish parity of esteem and clarify mutual dependencies between health and social care support, and to establish equity in terms of reporting arrangements. We recommend the creation of a National Care Service via which Ministers are empowered to discharge their responsibilities for adult social care support, to oversee delivery in local areas as set out in further detail below. In simple terms, we envisage a National Care Service that operates along these lines:
To ensure parity and clarity with the NHS we recommend that the Scottish Government should at the same time establish NHS Scotland in law on an equal footing to a National Care Service, to oversee delivery by individual NHS Boards.
Why not nationalisation?
We have considered whether nationalisation – taking all of adult social care into public ownership and management – is desirable.
The evidence suggests that nationalisation would not in and of itself improve outcomes for people using care. Care Inspectorate data indicates that, when it comes to community based services, quality is generally highest among third sector providers. In terms of residential care for older people, evidence from the pandemic indicates a correlation between size of care home and quality of care, with smaller facilities faring better than larger ones, but no evident link between type of ownership (public, private or third sector) and quality. We therefore think that the evidence does not support nationalisation into public ownership on the basis of improving the quality of care.
Notwithstanding quality, if nationalisation is supported by some people they need to explain how it would be paid for. We have considered public value and how much it would cost to take the social care sector into public ownership. Examples such as the purchase of Home Farm care home in Skye at a cost to the public purse of £900K during the Covid-19 pandemic suggest that nationalising the sector would require an unaffordable level of public outlay, particularly in terms of investment in capital. It would also be hugely time-consuming: time that could be better spent working with providers and people who use services to improve care. We have also considered more fundamental financial questions, like responding to unmet need for social care supports, which in our view should be the priority for financial solutions; we provide further detail in Chapter 11.
Different arguments and different solutions apply to the social care workforce. Material inconsistencies in terms and conditions, low pay, high turnover, lack of training and development, low esteem and long-standing gender-based unfairness need to be tackled consistently and fairly without undermining the arrangements that underpin good quality existing provision as above. A national approach – without nationalisation itself – is needed to resolve these unacceptable features of current employment arrangements, without removing the unquestionable value added by the diversity and specialism of the third sector in particular, and without dismantling organisations that are already doing a good job. We set out our recommendations for achieving fair work in social care support in Chapter 10.
Local planning for, and delivery of, adult social care support should continue and should build upon the progress made to date with integrating health and social care support. That progress has not, the evidence is clear, been sufficient so far to meet the Scottish Government's ambitions for integration, which are necessary and urgent to improve public wellbeing.
Currently, the onus to integrate health and social care support sits locally, with responsibility devolved to Health Boards, Local Authorities and Integration Authorities. Lack of integration at national level is contributing to unacceptable variation in local progress.
Integration Authorities are new organisations, created only a few years ago under the Public Bodies (Joint Working) (Scotland) Act 2014. They should be reformed to take full responsibility for the commissioning and procurement of adult social care support locally, accountable directly to the Scottish Government as part of the National Care Service. Local Authorities should no longer be responsible for commissioning and procuring adult social care support but can continue to provide social care services procured by reformed Integration Joint Boards. One model of integration, the Integration Joint Board, should be used throughout the country. There is no evidence that lead agency arrangements have delivered better results than Integration Joint Boards and consistency will be important in the new system to simplify governance arrangements and improve public understanding of who is responsible for what.
We heard evidence that those Integration Joint Boards, which have gone beyond the statutory delegation minimum of all adult social care, and that have all children's services and criminal justice social work also delegated, have performed well in relation to these services. It will be important in the implementation of this report to have regard to implementation plans for the review of children's services (The Promise) and of the work being done to consider the future of criminal justice social work. Social workers and their representative organisations expressed concerns about further fragmentation of the social work workforce, across different arrangements for those working in adult care, children's services and criminal justice. We fully recognise and value the role of social workers in respect of assessment and care management, and in changing the way self-directed support currently operates, as well as their critical role in adult support and protection.
Social workers were also concerned about the impact possible fragmentation would have on children, families and adults needing support and who do not lead their lives according to administrative boundaries or arrangements. Careful consideration should be given to these concerns as changes are taken forward and close joint working forged between the implementation of The Promise and the recommendations in this report.
As the local delivery agencies of a new National Care Service, Integration Joint Boards will need considerable support from the Scottish Government, Local Authorities, the NHS, and delivery partners, to make consistent progress. Contributing wholeheartedly to that support must be a priority for all partners in health and social care support in Scotland. There will be a continuing need for partners at a local level to work collegiately to share intelligence and understanding about local needs and to explore joint solutions. This will only be achieved by prioritising it and working together to achieve the best outcomes for local communities. The importance of clear, committed leadership at all levels and in every organisation to making a reformed system work cannot be overstated. We recommend the creation of a National Integration Joint Board where the senior leadership of the National Care Service and NHS meet regularly to agree strategy and priorities.
I was transitioned to adult care providers at the age of 16. The care provider I was initially given, wasn’t able to work with people who have physical disabilities, therefore was totally unsuited to meet my needs.
The British Red Cross stepped in and gave me a new outlook on life and the opportunity to have the independence I desired and I stayed with them for almost a decade. I am now in the process dividing my care package between Quarriers and Ayrshire Independent Living Network to better suit my requirements.
Transitioning from children services to adult services is a daunting experience. The communication between social worker and care provider could be improved to allow a steady transition, and in my situation there could have been better research into care services to ensure they met my requirements. The amount of paperwork support staff now need to complete has got out of control and takes away precious support time. This bothers me as I have to allow staff time away from caring for me to write reports. Support from team leaders and management to the service user is much less forthcoming since I transitioned to adult services and this should be improved to allow issues to be dealt with more effectively and positive relationships to be formed between management and the service users.
Overall, I’ve found my experience of transitioning between children services to adult services and between care providers steady and carefully considered over the years.
"The amount of paperwork support staff now need to complete has got out of control and takes away precious support time.”
Budgets for integrated health and social care support services should be determined nationally and distributed directly by the Scottish Government to Integration Joint Boards, as they are to Local Authorities and NHS Boards. This will mean that budgets that are currently distributed to Integration Joint Boards via Local Authorities and Health Boards will now be allocated directly by the Scottish Government. Too much time and effort is currently spent agreeing budgets for integrated health and social care support services at local level. We heard that budgets are often not agreed until well into the financial year in question. A new distribution formula for Integration Joint Board budgets is needed to ensure equity and transparency, rather than relying on a blend of the existing NHS and Local Authority formulae as at present. Such a formula will need careful development with partners to ensure a fair outcome for Integration Joint Boards, Local Authorities and Health Boards. Consideration will need to be given to VAT in relation to the National Care Service.
We set out our recommendations for how a new National Care Service should work in Chapter 6.
We recommend that a National Care Service should be established:
15. Accountability for social care support should move from local government to Scottish Ministers, and a Minister should be appointed with specific responsibility for Social Care.
16. A National Care Service for Scotland should be established in statute along with, on an equal footing, NHS Scotland, with both bodies reporting to Scottish Ministers.
17. The National Care Service should oversee local commissioning and procurement of social care and support by reformed Integration Joint Boards, with services procured from Local Authorities and third and independent sector providers. Integration Joint Boards should manage GPs' contractual arrangements, whether independent contractors or directly employed, to ensure integration of community care and support provision, to respect and support professional interdependencies, and to remove the current confusion about where responsibility for primary care sits.
18. The National Care Service should lead on the aspects of social care improvement and support that are best managed once for Scotland, such as workforce development and improvement programmes to raise standards of care and support.
19. The National Care Service should oversee social care provision at national level for people whose needs are very complex or highly specialist and for services such as prison social care that could be better managed on a once-for-Scotland basis.
20. The National Care Service's driving focus should be improvements in the consistency, quality and equity of care and support experienced by service users, their families and carers, and improvements in the conditions of employment, training and development of the workforce.