Fiona Duncan: One question and one question only series: What are the challenges and risks of the creation of a single National Care Service to #KeepThePromise?

At the beginning of last month, the ‘One Question and One Question only’ article in this short series about the Scottish Government consultation into the National Care Service considered the possible opportunities one single organisation could offer.

The focus for this article is the challenges and risks.

At the time of writing, there are just over three weeks until the consultation closes. The proposed timeline beyond the consultation closing on 2^nd November is; a summary of responses published in January, Cabinet deliberation in March and the Bill laid before Parliament in June.  2022 – 2023 has been designated as the design phase and 2024 -2026 when the National Care Service, in whatever form it ultimately takes, is operationalised.

The Promise Scotland continues to work on its response, assessing the implications of the proposed National Care Service on Scotland’s commitment to #KeepThePromise.

The team are doing this by revisiting the Independent Care Review’s Evidence Framework that informed its 80+ calls to action contained the promise and the vision it painted for Scotland, along with the conclusions detailed in the other Care Review reports published last February - follow the money, the rules and the plan.

The Promise Scotland team are also re-examining the cross-referencing work they carried out in February of this year when the Review of Adult Social Care published its 53 recommendations, mapping these against the Independent Care Review reports published a year earlier.

Although the conclusions and recommendations of both Reviews were accepted in full in Parliament, fully amalgamating them will not be straightforward, especially on the issues where they reached divergent positions. One of the most obvious is profit.

The Care Review was clear that ‘Scotland must make sure that its most vulnerable children are not profited from’. The Review of Adult Social Care called for the ‘development of a new approach to ethical and collaborative commissioning’ with the authors noting their unease at the “leakage” of significant sums of money out of the care economy system, as the adult social care system is one that is largely run on a profit-making basis.

Very thoughtful consideration would need to be given as to how to bring together areas of incompatibility, without making compromises.

Profit is not the only area that would require very careful navigation to avoid clumsy alignment, which would be to the detriment of both. Or worse still become untenable.

Critically the Promise Scotland team are also meticulously reviewing the implications on the current and live implementation to #KeepThePromise in full by 2030 happening all over Scotland.

This is itself a risk.

Bringing together the planned implementation of the Independent Review of Adult Social Care with the ongoing implementation of the Independent Care Review without derailing progress made over the last 18 months will be a challenge. Scotland’s ‘care system’ has accepted the need to change and share a vision about what good looks like for children and families, it has demonstrated ‘buy-in’ to #KeepThePromise and there is real momentum.

Change is happening, with more planned, as outlined in Plan 21-24 which was devised collaboratively last year and still has over two years of work ahead.

A good starting point, if they are to be brought together, is an appreciation of the different approaches the two reviews took, as reflected in ‘form follows function’ principle:

• the Independent Review of Adult Social Care was a 2020 Programme for Government commitment ‘to examine how adult social care can be most effectively reformed to deliver a national approach to care and support services. This will include consideration of a National Care Service’: form.
• the Independent Care Review was a promise made by the First Minister at the SNP 2016 Party Conference to the care community of a ‘root and branch review of the care system’ ‘to love our most vulnerable children and give them the childhood they deserve’ with a focus on the experience of the system: function.

The consequences of this can be seen in the difference in how conclusions are framed.

To avoid the danger of not creating a ‘new’ National Care Service, but instead just adding ‘more’ to already cluttered, fragmented landscapes, will require a comprehensive understanding of how the respective systems - and services - could work together, nationally and locally, and what could get in the way – no insignificant task. 

The Care Review identified the negative impact of the currently overcrowded, fragmented bureaucracy on those it is meant to serve, and as the rules made clear children, adults and families can fall into the resultant disconnects and ‘childhoods can get lost’.

Rather than streamlining and simplifying, the amalgamation of adult and children and families social care plus justice, could introduce a new set of obstacles for people to navigate.

Scottish Government would be required to demonstrate its ability to pull together currently siloed policy areas to better reflect the real-life experiences of children and families.

And even if this was all achieved, it could lead to another significant concern.

There are more adults in the social care system than children and families and, with an ageing population, this is likely to increase. The Care Review’s premise, that more families will stay together where safe to do so, assumes that the number of children, young people and families who come into contact with the ‘care system’ will shrink. A single National Care Service, designed to accommodate the larger and growing demographic of adults who need support, risks eclipsing children and families, obscuring their needs and making it harder, not easier to access support. The bigger service becomes the standard; the smaller, the outlier required to flex and shift to accommodate particular ways of working, processes, language, and so on.

A single National Care Service with all social work disciplines (adults, children and families and justice) delivering local universal services and specialist care underpinned with services currently sited in the National Health Service could have real benefits - but only if it meant that children and families could access seamless services that impact positively on their experiences and outcomes.

As the Promise Scotland team have been working their way through the consultation response, it has become very apparent that there is no straightforward, easy or binary answer to the question, would a National Care Service #KeepThePromise? However, The Promise Scotland will prepare a submission that is focused only on the commitment that Scotland made to its children and families in February 2020, after listening carefully for three years.

The last entry in this series will focus on the methodology behind The Promise Scotland’s consultation submission.

About the author

Photo credit: Sarah Maclean

Fiona Duncan

Independent Strategic Advisor

Fiona Duncan is the Independent Strategic Advisor on the promise, and advises Scottish Ministers in this capacity.