Could a National Care Service work like the National Health Service?

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This blog will outline what we know so far about how the Scottish Government propose to reform social care in Scotland. It will illustrate in simple terms how the NHS currently differs profoundly from social care.  This blog is slightly longer than normal, and so to ease navigation we’ve added a contents popup below:

What commitments has the Scottish Government made?

In the debate on 1 June on the National Health Service Recovery Plan, both the Cabinet Secretary  for Health, Social Care and Sport and the Minister for Mental Wellbeing and Social Care made clear the government’s intentions for a national care service:

Our commitment to create a national care service will deliver services that are founded on fairness, equality and human rights, and will place that service on the same level of esteem as our national health service. The creation of a national care service will be the most significant public sector reform since the creation of the NHS in 1948, and the service will be operational within the five-year lifetime of this Parliament. In our first 100 days, we will begin the consultation on the necessary legislation, with a view to introducing it in the first year of the session. We will also establish a social covenant steering group that includes people with lived experience who use our care services, to ensure that they are part of the co-design process…

…we are committed to the creation of a national care service, which will be backed by a 25 per cent increase in investment in social care over the parliamentary session. We will build a world-leading social care system that will be based on fairness, equality and human rights, and it will provide us with the consistency, equity and fairness, as well as the national approach and accountabilities, that we need to improve social care in Scotland.”

In its election manifesto the SNP also said they would:

“ensure enhanced pay and conditions for workers and provide better support for unpaid carers.” They would also “improve standards, training and pay across the board… review the number, structure and regulation of health boards to remove unwarranted duplication of functions” and would deliver “over £800 million of increased support for social care (and) abolish charges for non-residential care”

The Scottish Government are basing their ideas for reform on the Independent Review of Adult Social Care, chaired by Derek Feeley, published in February 2021.

In her response to its publication, the then Cabinet Secretary for Health and Sport, Jeane Freeman said:

“The independent review of social care gives us a clear roadmap for the future of care provision in Scotland and we believe in the recommendations in this report.”

Some big questions are already surfacing…

Audit Scotland have asked:

  • How the national care service will be funded?
  • What the extent of complex structural change will be?
  • Where responsibility for the National Care service will lie – with Scottish Ministers or with integration authorities, or with local authorities, as social care does now?

These are the big questions. Since the election, the government has set out its intentions for the first hundred days of the new Parliament.

In her Statement on 26 May, the First Minister outlined the government’s priorities:

“I can confirm that in our first hundred days, we will legislate to ensure that all those who receive the Carers Allowance Supplement will receive a double payment – worth £460 – in December of this year. 

And in our first one hundred days, we will begin the consultation on legislation to establish a National Care Service.

We intend to introduce the legislation during the first year of this parliament, and expect the service to be operational by the end of the parliament.

This will be, in my view, the most important public sector innovation since the establishment of our National Health service.”

Will a national care service be the same sort of service as the NHS?

The table shows how little the NHS and social care provision have in common. So, despite the existence of integrated health and social care, and health and social care partnerships, the structural differences remain.

From the table, we can see that these structural differences between the NHS and social care in Scotland are profound.

Strategic planning and commissioning of services through:
14 health boards in collaboration with 31 integration authorities
Local authorities in collaboration with 31 integration authorities (and 14 health boards)
Delivery through:
14 health boards/31 health and social care partnerships (integration authorities)
Mixed economy of:
– integration authority (health and social care partnership),
– private and
– third sector provision.  
(around 70% delivered by independent sector)  
NHS boards are directly accountable to the Scottish Ministers.

However, integration legislation introduced joint governance arrangements with integration authorities. Members of health boards are appointed by ministers through a public appointments process  
Local authorities are responsible for arranging and procuring social care services for their local population. They operate independently of central government and are accountable to their local electorates.

Integration authority boards comprise members nominated from health boards and the local authority (councillors) along with a number of other designated representatives.

The chief officer of the integration authority is appointed by the authority’s board and employed by either the NHS board or the local authority, creating joint and complex accountability.  
Service providers (and their governance if not a public body)
Health boards and health and social care partnerships
Health and social care partnerships.(delivery of services planned and commissioned by integration authorities)

Third-sector-run services are governed by a range of structures, depending on how they are constituted. Their services might be commissioned by the integration authority.

Private sector corporate governance will depend on the legal status of the business. In larger companies it will involve establishing a framework of systems and controls to act in the best interest of the shareholders. Whereas in family owned businesses and SMEs (where the owners may also be the management) the focus is mainly about complying with regulations and improving performance.   Their services might be commissioned by the integration authority  
How is it funded?
Centrally by Scottish Government to health boards (bulk of budget directed by integration authority). Largely free at the point of delivery to the resident population.
Social Care (except for personal and nursing care) is means-tested meaning that individuals might contribute financially to their care.

When assessed as being required, care and support is funded by local authorities (budget directed by integration authority). National eligibility criteria apply when local authorities assess someone’s care and support needs. It is mostly those who are in ‘substantial’ or ‘critical’ need who are prioritised when needs are assessed. This means there is unmet need for those with moderate or low needs, when resources are under pressure.

Accommodation (care home) costs and some other services to those living at home, such as alarms, delivered meals and day care services, are means tested and charged for. A large proportion of people pay care home fees to providers in all sectors (public, third sector, private).

People assessed by social services as needing personal care and nursing care do not pay for these services, wherever they live.
Location of care
Hospitals (Secondary care) GPs, Dentists, Pharmacies etc (Primary care) Hospital at home
In people’s homes and community settings, such as supported living and day care centres.

Private care homes, third sector-run homes, Health and Social Care Partnership homes.
How are services regulated?
There are a range of ways, including through the  Healthcare standards, by which the Scottish Government, and ultimately the Scottish Parliament, oversee the work of the NHS in Scotland. Areas where there is particular focus are performance and waiting times, financial stability, improvement science, clinical safety and the duty of candour.
All care services must be registered with the Care Inspectorate and abide by  the Health and Care Standards (ie not the same as the Healthcare standards).
Staffing – terms and conditions
Most staff are employed directly by the NHS under ‘Agenda for Change’ employment contracts, negotiated nationally. Some staff are independent contractors, such as most GPs,dentists and pharmacists. These contractors work to nationally negotiated contracts. Their contract is with the local health board.
Terms and conditions will vary widely across the sector. However, in the case of care home and homecare services, these are delivered and managed directly by local authorities/health and social care partnerships. Staff terms and conditions will tend to be better than in the private sector, and be nationally negotiated.
Staffing – regulation
Clinical and nursing staff must be registered with one of the national (UK) professional councils, such as the General Medical Council, the Nursing and Midwifery Council or the Health and CareProfessions Council
All staff are to be registered with the Scottish Social Services Council (SSSC) within six months of starting a new role. Staff must abide by the SSSC codes of practice.

What has the Scottish Parliament said on the need for reform?

For a more detailed overview of how adult social care and support operates in Scotland, SPICe published a briefing to support the Session 5 Health and Sport Committee’s inquiry into social care. This SPICe Twentieth Anniversary blog, published prior to the Feeley review, also considers social care in the context of the integration of health and social care.

What does the Independent Review of Adult Social Care(IRASC) wish to see?

The Review was commissioned on 1 September 2020, with an aim to recommend improvements to adult social care in Scotland. These were to be in terms of outcomes for people who use the services and work in the sector. Feeley does address many issues in his Review, such as:

  • the low status of care work and low pay
  • how social care should be funded
  • human rights
  • commissioning
  • unpaid carers
  • accountability.

He makes many recommendations. However, it was not part of the remit to lay out how it should all work in detail. The Review seeks a shift in thinking – from “negative” to “positive” thinking. So, for example in the Review, rather than being a burden on society, social care and support for people is an investment; rather than crisis management; it is preventative and anticipatory; rather than competition, it is about collaboration between all parties; and about outcomes rather than outputs.

In a note of a meeting (17 December 2020), Feeley set out five clear guiding principles that were informing the draft report, but which don’t appear so succinctly in the final version:

  • Shift from outputs to outcomes
  • Shift from competition to collaboration
  • Shift from short term to long term
  • Shift from cost driven staff arrangements to Fair Work
  • Shift from price to quality

The elephant in the room – who will be accountable?

A major potential sticking point for the proposed national care service is whether accountability and overall governance will shift from local authorities to national government. Feeley recommends that it does.This would require major reform and legislation. Feeley says that:

“The changes we propose here would likely not be necessary if more progress had been made by the Scottish Government, Health Boards, Local Authorities and Integration Joint Boards with integrating health and social care. Wishing it were so does not make it true, however.”

He recommends that:

“new legislation should empower Scottish Ministers to:

  • Discharge responsibility for the local planning, commissioning and procurement of social care support via Integration Joint Boards; and
  • Create national bodies to service and support social care support and social work at local and national level.

Ministers should be able to change the number and configuration of Integration Joint Boards and national care bodies without changing primary legislation. This approach mirrors the existing powers of Ministers to establish NHS territorial and special boards.”

So, Feeley proposes that reform aligns with changes already seen in the integration of health and social care, and changes the status and operation of integration authorities. On 24 March 2021, and following publication of the Review, the Scottish Government and COSLA issued a joint statement of intent to “work together to deliver the key foundation pillars set out in the recently published Independent Review of Adult Social Care in Scotland (IRASC)”.

The focus of the statement is to prioritise a national fair work framework. By May 2021 they agreed to also have outline plans in place to deliver:

  • an end to charging for non-residential services as soon as possible
  • shared ethical commissioning principles
  • the overhaul of the current mechanism of eligibility criteria to ensure an approach to social care support that is based on human rights and needs
  • a mechanism which ensures the voices of those with lived experience are at the heart of policy development, service design and service delivery
  • ensuring that unpaid carers are fully supported to have a life alongside caring, in order to protect their health and wellbeing and better sustain caring roles.

You will notice that none of these addresses the thorny accountability and governance questions, and the statement acknowledges this. It is not clear whether the plans have been prepared yet.

COSLA issued a response to the Feeley Report, expressing the ‘grave concern’ of Council Leaders at the:

“recommendations around the future governance and accountability arrangements contained within the Report… Council Leaders together voiced their opposition to the recommendation which proposes the removal of local democratic accountability from Adult Social Care and the centralising of the service under a National Care Service with accountability falling to Ministers, a move that they described as being detrimental to the local delivery of social care and its integration with other key community services.  They also felt that given the level of funding set out in the Review, Local Government would be well placed to continue to deliver this vital service.

Perhaps the work already done in integrating health and social care will be enough to facilitate the changes necessary to create an equitable national care service: one that delivers the outcomes desired by all those seeking care and support, especially as they become more vulnerable in older age. Feeley thinks not, however.

If these big questions are not addressed what will this mean for the Review’s many substantive and comprehensive recommendations?

Anne Jepson, Senior Researcher, Health and Social Care

Feature images from: Age-positive image library, catuira (creative commons)