The campaign for a National Care Service in Scotland: a contribution to a discussion. By HILARY HORROCKS (Edinburgh trades union council delegate). This article was first published on the People and Nature blog. We repost it here with the author’s permission.

Health is a devolved matter in the not-so-United Kingdom, and that has allowed successive Scottish governments to bring in progressive measures that are missing in England, such as abolition of prescription charges for everyone and free personal care for the elderly.

The Scottish National Party (SNP) government certainly sought to distance itself from Westminster during the first stages of the Covid pandemic, when it seemed to follow scientific advice more carefully, and kept the public better informed with daily briefings by the First Minister.

Between the first and second waves of Covid last year the virus was just about eliminated in Scotland – but like Westminster, the government at Holyrood failed to use the summer to bring in mitigating measures to reduce infection. So in the autumn, the return of schools and universities, coupled with the loosening of restrictions, led to a rise in cases similar to England’s.

Mask wearing has remained a legal requirement in Scotland, including for all secondary school pupils, and is generally well observed – but cases remain worryingly high, particularly in poorer areas.

Here, as in England and Wales, the terrible toll of deaths in care homes at the beginning of the pandemic brutally exposed the disastrous policy of freeing up NHS beds by transferring elderly hospital patients to care homes with no proper testing.

In the aftermath, the Scottish government commissioned an independent report on Adult Social Care (the Feeley Report), which recommended setting up a National Care Service (NCS).

In addition to the care homes scandal, social care in Scotland is beset with problems, exacerbated, as they are everywhere, by deindustrialisation and consequent social deprivation; decades of austerity; and the loss of skilled care workers because of Covid and Brexit.

Nowhere is the crisis more painfully clear, perhaps, than in the tragic rate of drugs deaths among young people, now at a record high.

The Scottish government has put out a long document listing their proposals for the NCS. These formed part of the SNP manifesto at the Scottish elections in May, in which it emerged the largest party and now governs in a working coalition with the Greens. Their proposals, designed to cover those with mental or physical disabilities, the elderly, those with dementia, recovering from alcohol or drug addictions, the homeless, children and families needing support, will, they say, be implemented within a year.

The guiding principles in the document sound promising at first sight: ensuring that care is person-centred, human-rights based, and is seen as an investment in society; nurturing and strengthening the workforce, and giving greater recognition to and support for unpaid carers.

The title of the plan – a National Care Service – is obviously designed to evoke parallels with the setting up of the National Health Service in 1947 and its radical reform of state welfare. However, it is anything but. Crucially, it fails to recognise the devastating impact of cuts to health and welfare and of the inroads of privatisation; and, in general, it does not move the debate beyond a neo-liberal framework.

The proposals are out for public consultation. The public can give its views in an interactive version of the document. However, you are restricted to giving responses to set questions, many of which don’t address the substantive issues. But unions, community groups and others are responding with their own independent contributions.

What follows is a summary of their most important criticisms, and is designed to open a discussion, not only in Scotland.

The role of care in society

“Care needs to be recognised as a social good”, Mark Smith, a researcher of social care, has written. “This is compromised by continuing to locate it within an economic system the primary motive of which is profit maximisation.”   

A fundamental criticism of the Scottish government’s proposals is that no amount of government directive can make a difference, and that root-and-branch reform is needed.

“Most insiders in the profession recognise that the social work system is pretty broken”, Colin Turbett, a frontline social worker in the West of Scotland for nearly 40 years and author of Doing Radical Social Work(2014), says.

In the past few decades, he continues, the role of social workers has become restricted to the performance of statutory public protection duties, instead of the broader preventative welfare role they performed in the past.

“They only become involved when the situations of the people they work with might be beyond help, their skills being largely spent trying to mop up when earlier involvement might have prevented escalation.”

Social workers typically spend most of their time behind  computer screens, rather than engaged with the individuals who need their help.

A public service

Critics of the NCS proposals insist that it should be a public service, completely not-for-profit, and principally delivered through local authorities. The Scottish government, in contrast, envisages a continuing role for the private sector, currently owners of 80% of care provision in Scotland.

This, despite the fact that the private sector is leeching funds out of care provision into property speculation or offshore tax havens; and that the record of privately-run care is far from good.

One of the major providers, Advinia Health Care, who own 11 care homes in Scotland, were second on the list of those homes that saw the most deaths during the first Covid wave.

The Scottish government and the health authorities directed the evacuation from hospitals to care homes, apparently blind to the fact that the care providers most likely to accept patients were those most motivated by profit.

Advinia Health Care is ultimately owned by a company registered in the tax haven of Gibraltar and has been the subject of an attempted financial investigation by the regulator in England. The Care Inspectorate reported in May of this year that they had found in one Advinia home unsafe disposal, storage and management of clinical waste, including PPE, while staff had not been given the correct PPE or shown how to use it properly. 

The commitment of the Scottish government to the private sector in the context of its NCS proposals was confirmed, alarmingly, when it emerged recently that the £100,000 contract for the initial design of the proposed new care service had been awarded, even before any consultation has been concluded, to the Edinburgh branch of PriceWaterhouseCooper.

Scottish TUC general secretary Roz Foyer commented: “While this is only a small contract, beginnings matter. South of the border, the past year has seen the continued growth of the consultancy gravy train with massive contracts awarded to companies with clear interests in private-sector provision of public services. We do not want this replicated in Scotland.”

How can a National Care Service be funded?

The Scottish government points to the inadequate provision of social care by local authorities, completely failing to acknowledge the harm inflicted by decades of cuts to council funding. 

Only with proper funding can local authorities build up the infrastructure that would allow them to absorb, in a National Care Service, not only the current private/third sector provision of social care in the medium term, but also the increasing demands on social care in the long term.

The government, say campaigners, should ring-fence resources to provide good-quality care and fair pay and working conditions to carers, who should be respected as skilled workers. Collective bargaining must be set up immediately to agree national pay and conditions between a National Care Service and trade union representatives, and to provide regular high-quality training.   

Common Weal, a Scottish-based “think-and-do tank”, argues in its Manifesto for a National Care Service that private providers should be bought out, as happened when the NHS was set up, but over time.

Given the parasitic nature of private care, isn’t there an argument for a more radical move? Private providers could be offered a role in a publicly-funded system, subject to stringent checks, but they should not be offered compensation.

Free at the point of need

On charging for care, the Common Weal Manifesto says: “All charges for care would be abolished. The National Care Service should be funded from the public purse, either from tax or a new national insurance scheme based on a universal “pooling of risks” with all contributing as per their income, irrespective of the care they may or may not receive.”

In accommodation-based services, Common Weal argues, “people would be expected to contribute a portion of their income […] [they] would no longer be required to sell their assets to pay for residential care.

“The funding shortfall should be met through a more equitable system of inheritance tax, in which the rich pay more than those who bought their council houses, or through other taxes.”

What about local control and accountability?

The Scottish government proposes that under a new care service, local councils would hand over ALL their current social care and social work responsibilities to management bodies called Integrated Joint Boards.

These have already been in place for some years, and they have been proved not to work. Elected councillors do sit on them, but in practice get overruled on local decisions.  

And the government’s new care service would be ultimately accountable to a government minister, meaning more centralisation and less ability to create and administer services at a local level, where they are most effective.  Common Weal describes the government’s NCS as “an attempted power grab by central government and a further assault on local democracy”.

Campaigners envisage an NCS run by local authorities, as the existing democratically elected and accountable bodies, but also call for a further devolution of care services to local community hubs, which “can actively involve service providers, those needing care and those with lived experience to create local, flexible, inclusive services”, as the Edinburgh Trades Union Council (TUC) response to the government’s proposals put it.

The idea of community hubs as centres for public service delivery and voluntary activity has been revived during the pandemic. “Notions of community empowerment already enshrined in law”, Common Weal says, “ought to be compatible with the decentralisation of public services and bottom-up community partnership and control. The National Care Service that Scotland needs could be managed and delivered at local level through community hubs.”

Above all, providers, workers in the service, and users, have to be involved in the planning and management of social care. “People in Scotland deserve far better”, says one of the Common Weal team, “but we will not get that so long as those responsible for the current system are responsible for redesigning it”.