Nick Kempe outlines the key principles and values that must underpin the reform of care in Scotland.
The Scottish Government’s ‘Independent Review of Adult Social Care’, conducted by Derek Feeley, is due to report at the end of January and will ‘include consideration of a National Care Service’ (NCS). The principles upon which such a service would need to be based are not, however, within the review’s remit. Instead, it has already decided its recommendations will be based on a human rights approach. Arguably, such an approach has now been promoted in Scotland for the users of services and their carers, if not the workforce, for almost twenty years. The National Care Standards, published in 2002, were intended to put concepts such as respect, dignity, privacy and choice at the centre of service provision. All subsequent social policy has reinforced this commitment. All that, however, has unravelled in the Covid crisis during which the human rights of people who receive and deliver social care services have been trampled over, from the failure to provide frontline staff with proper PPE to the continued denial of contact between care home residents and their relatives. Without taking a wider view, human rights approaches are likely to remain a toothless tiger. Ensuring social care is properly resourced, for example, so that all who need care receive it, is necessary if any rights to care are to be enforceable. In a 2020 paper entitled ‘Care after Covid’ for the Jimmy Reid Foundation, Gregor Gall argued the need to develop a set of principles to underpin a future NCS. This article takes up the challenge.
Our starting point should be that the NCS should be a universal service from cradle to the grave. Nothing less will embed it in people’s affections like the NHS. The Feeley Review’s remit is restricted to adult social care when last year, another Independent Care Review (ICR), for children, produced some radical recommendations for reform which were accepted by the Scottish Government. We don’t need two care systems and the findings of the Children’s ICR should have formed a stepping stone to a NCS. People who need care services as children continue to need care and support as they grow older, as is evidenced by the levels of suicide, addiction and mental health breakdown among young people who have experienced care and the problems children with disabilities face in the transition from children’s to adult services. Any set of principle for a NCS need to encompass people of all ages.
A second principle is that, like health, what counts as care must be broadly defined. In 2002, the Scottish Parliament introduced ‘Free Personal and Nursing Care’ to address some of the anomalies created by councils taking over responsibility for services that been free under the NHS. Eighteen years later eligibility criteria have been tightened and, in many areas, the only care councils now provide is that which comes under the official definition of ‘personal care’ tasks. That definition, inadvertently, helped create the 15-minute home care visit, where workers hardly had time to say hello, while ticking off tasks from the personal care list. Other forms of care, from practical support to helping a person with their social and emotional well-being, are now deemed low priority, with charges an additional deterrent for people who dare to ask for assistance. The result is that much care provision has become inhuman and only the rich, who can afford to buy what they want, receive the care they really need.
This leads to a third principle, namely, that care provision should be relationship based. The ICR for children concluded that relationships should be at the centre of the care system. Good care is dependent on mutuality, with people feeling comfortable and trusting those who care for them, not having a different carer every day and having some control over when they receive help. Experience of this not happening, rightly, helped drive demand from people with disabilities to take control over the services they receive. This means users of the NCS and their informal carers should be empowered to control the services that support them as far they are able. These two points have numerous implications for the delivery of services, from the time a carer has to spend with someone, to the personal qualities, skills and knowledge that they require to relate effectively to people, every one of whom is unique. But they also have implications for the way care services are negotiated and organised. That requires a set of skills that used to be provided by social workers before they were turned into gatekeepers under the Community Care Act 1990 and then stripped out of most services for adults. There is now a professional skills gap at the heart of social care. A start would be to think about how we make social workers and social work as central to a NCS as doctors and medicine are to the NHS.
Under the current system, frontline care staff can start working with some of the most vulnerable people in our society without training, so long as they commit to obtaining a relevant vocational qualification. This they are often required to do so in their own time and, unsurprisingly, many leave before they have done so. The right of all care staff to be properly trained, including paid induction and a minimum number of days training each year, must therefore be integral to the NCS. We also need to end the exploitation of staff, mainly women, as was illustrated in Ken Loach’s Sorry We Missed You. Abbie is a home carer whose own family are on the brink, in no small measure because of low pay. When she doesn’t have the time to help an older person properly one day, she returns in her own time in the evening, unpaid. The consequences for her own family are tragic. Abbie does the right thing but it is scandalous that thousands of underpaid workers are being put into similar positions each day. The NCS needs, like the NHS, to be based on national pay scales and national pay and conditions which are agreed through national collective bargaining.
Part of the way a NCS could meet the costs of improved pay and conditions is to stop money being extracted from the system in profit. In Scotland, the law already requires foster care services to be not for profit and there appears to be no legal impediment to extending this to all services. As well as removing businesses which have no interest in care, a significant proportion of whom are based in tax havens, from the system, we need to create a NCS people want to support financially, whether through taxes or, where they have them, their own resources. No-one is ever likely to want to leave money to a private care home but self-funders, who are currently ripped off by extortionate fees, might leave money to services that were devoted to care, not profit. This happens with the hospices that operate within the NHS.
This brings us to charging and here the NCS should like the NHS be free at point of use. That would also be a logical consequence of shifting the focus of services from personal care to relationship-based care. Contrary to neo-liberal ideology, popular affection for the NHS shows that charging is not what makes people value services. The challenge for our politicians is to find other ways of funding the NCS.
While many of these principles should be relatively simple to articulate and agree, there are others that are likely to require significant debate. The first concerns the balance between individual rights and collective needs. The idea that care is a commodity, which can be chosen and bought, has been the driving force behind much social care reform since ‘new’ Labour. Choice is the justification the private care home sector give for their continued existence. The problem is wants are not needs, care involves compromises all on sides, and choice doesn’t work without money. There is little point in having individual budgets if they are insufficient to pay for the care people need. Since then, austerity that is now the norm, not the exception. Covid-19 has exposed the weaknesses of Self-Directed Support ideology still further, with people losing services and being discharged from hospital to care homes without consultation.
As a corollary, Covid-19 has also shown that ultimately, we are all in this together, that the rights of people needing care, their carers and the workforce are all important. We need new ways to address these issues and key to this is the democratisation of services. Imagine that each care home in Scotland had had a committee made up of staff, residents and their relatives with powers to make decisions. Would they have done any worse than government in mitigating the impacts of Covid-19? Given the chance, they could have come up with practical solutions to problems the Scottish Government and Health and Social Care Partnerships (HSCPs) have proved incapable of solving, like how to enable relatives to visit care home residents safely.
This raises the question of how should we resolve the tensions between a universal service with a homogeneous set of standards, necessary to some extent to prevent care becoming a postcode lottery, and the need for innovation and diversity to reflect local circumstances and local decision-making. There are no easy answers, but it would help to have a principle that informed decision-making was based upon, however, the NCS was organised.
And, lastly, there is the status of the NCS. There is a strong argument that it should an independent service separate from the NHS. That might appear contrary to the cross-party policy drive of the last ten years to integrate social care with health but that so far has had little obvious success. The chasm between primary and secondary care in the NHS remains and, with Health and Social Care Partnerships (HSCPs) close to financial collapse, the evidence suggests that neither the NHS nor councils have the resources to make them work. So why not use the HSCPs to form the building blocks of the new NCS and fund it independently? That is probably the only way to ensure that care is fully resourced. The NCS could then be designed to interface with the NHS on the one hand, with some community health staff with caring roles transferring over, and even more importantly on the other, with local communities, community services and the informal carers who provide the majority of care in Scotland.
Human rights and a National Care Service are both powerful ideas that could help drive political change. But they will need to be founded on a new set of principles if we are to achieve the sort of radical reform that our care system so urgently requires.
Nick Kempe was Head of Service for Adults and Older People in Glasgow and convenes Common Weal’s Care Reform Group which is developing a blueprint for a National Care Service in Scotland.