Anyone who has ever had the misfortune to arrange social care and support for an elderly relative, disabled adult or a child with additional support needs will know just how broken the system is. The fault line exists in the artificial distinction between health and social work services. Remember the ridiculous squabbling over whether a bath constituted a nursing or social bath when free personal care was introduced? It neatly summed up the absurdity of the situation that continues to exist for many, especially those under 65.
Worst of all, even after an individual has been assessed as requiring a particular package of support, the thorny issue of who pays is rarely resolved amicably. People can wait months to receive a care service, while health and social work professionals play pass the parcel with the costs, jealously guarding their budgets as though they were paying out of their own pockets.
This is what leads to the phenomenon referred to carelessly as bed blocking but which means in practice, an old person confined to a hospital bed, imprisoned when they should be at home or in more amenable surroundings, growing more miserable by the day.
So, the recent announcements from both Labour and the SNP that they will move to a single care service, initially for elderly people, are to be welcomed. But the chosen solution from both – to move all social care within the ambit of the NHS – is deeply flawed, for it assumes that the NHS is best placed to deliver such services.
It is not. This reform misses a once in a lifetime opportunity to move to a care system that designs, plans and delivers care services around the individuals who use them, rather than the institutions that provide them.
If we are serious about changing how we provide services like social care so that they are more efficient and effective, we must embrace a truly centred people approach. This requires transformational change: to move social care into the health service to create a single point of entry is insufficient. We need a new, single service for older people. And a similar one for adults, one for young people, and one for children. Then we move, change and create the types of services and resources each of these groups need in order to live fulfilling lives.
The current proposals will not resolve the thorniest issue of all, that of funding. Maintaining the divide between commissioner and deliverer will ensure that wrangles over money will continue. Instead of the provider holding the purse strings we need to empower service users by passing budgets to them. Interestingly, this approach is now being rolled out in England through the concept of individualised budgets, yet it has been ignored in Scotland.
Moreover, Shona Robison, our Public Health Minister, appears to rule out involving private providers instead of the public sector and points to English success in similar pilot integrated care services. But this ignores the reality that private – and especially voluntary sector organisations – are an essential part of the mix in Scotland. Indeed, some of the highest quality and most innovative services are developed and provided by charities and increasingly, social enterprises. This mixed economy is far less well developed in England, which is perhaps one reason why the pilots have worked there.
Most Scottish local authorities could not provide the current level of community care services without the involvement of private and voluntary providers. A significant proportion of services are already commissioned from others, because they can provide the care more effectively and efficiently. The NHS has proven stubbornly intransigent to the idea of a mixed economy and to engage with other providers who are better placed than themselves to deliver actual services.
One presumes that the government’s plan to shift to an integrated care service located within the NHS will remove current arrangements and put many of these longstanding organisations out of business. What will happen to their many thousands of staff, the ones engaged in the front line of care provision? What will happen to all that expertise, skills and knowledge?
The announcement also implies that staff transferring from local authorities to the NHS will have their current terms and conditions protected. Another curious point, for the reality is that many equivalent posts in councils, such as for social workers, tend to be on lower pay scales than those in the NHS. What will be required is not preservation but harmonisation, or else a two tier system of pay and conditions will be created that will leave the NHS open to legal challenge. Shifting staff over will cost money not save it, as employee costs will increase.
Reforming public services is essential but we must fashion new ways of designing and delivering services. The integrated care service proposal is a good one in theory but simply taking a broken system and jamming it into one part of the current set up represents a retrograde step. We are going back to the 20th Century not forward into the 21st.
The solution to our current financial woes and to our demographic challenges is not to retrench to centralised, state-controlled, top-down service design and delivery, but to look for community based approaches, that invest in localised services centred on the needs of individuals. We need to create lesser dependency on the state to provide for us and generate greater resilience in our population to support ourselves and each other within our local communities.
No one can fault the ambition inherent in the Scottish Government’s proposal but it is unfortunate that the prescribed solution ignores the reality of Scotland’s social care system and will ultimately fail to resolve current problems. The SNP and Labour need to realise that the NHS might not be the panacea for all our ills.