Nick Kempe: It’s time for debate on a National Care Service for Scotland

“The advantages of one National Care Service aligned with the NHS would be considerable… Instead of providers competing with the NHS for scarce staff, resources could be planned and deployed where most needed.”

A FEW MONTHS before its defeat in the 2010 General Election, the last UK Labour Government published a white paper called ‘Building a National Care Service’. Eleven years after it had been recommended in the Sutherland Report and eight years after the Lib-Lab government at Holyrood introduced free personal care for older people in Scotland, Gordon Brown promised to do the same in England and for all adults.

The rest of the white paper was premised on New Labour ideas: the declared intention was to improve public sector “performance” by joining up health and social work, and to make the system fairer by standardising assessments and eligibility criteria for services. Once assessed, the assumption was that all that mattered was individual choice and markets. People would be awarded a budget and supported to arrange their own services. This was just one year before the financial collapse of Southern Cross, the largest care home provider in the UK.

In the decade since the white paper, many of its ideas have been introduced in Scotland with cross-party support: self-directed support in 2013, Health and Social Care Partnerships in 2016 and free personal care for adults in 2019. During this period in England, the focus of the Tories has been on deregulating the market further while fruitlessly investigating ways to fund social care. Since the Sutherland Commission in 1999 there have been 12 white papers, green papers and consultations but very little progress.

The declared challenge has been how to fund social care, and more specifically how to pay for care homes, without forcing people to sell their houses. After Boris Johnson announced in his first speech as prime minister that he was going to fix social care “once and for all” with a “ready-to-go” plan, currently his government has no plans at all.

The Scottish Government has also avoided the funding challenge, perhaps in part because of its limited powers. Instead, it has tried to manage social care within its allocated budget. Coupled with its decision to protect the NHS rather than local authorities, social care has been hit particularly hard. This has resulted in a relentless pressure to cut services and those working in them. While already in crisis, Covid-19 brought all the failings to a head when c1,400 older people, stuck in hospital due to lack of funding, were suddenly discharged to care homes unprepared to care for them to order to free up capacity in the NHS.  

In the meantime the Labour Party, rejuvenated policy-wise under Jeremy Corbyn, had been working with trade unions and others to develop the idea of a national care service as an alternative to the current system in both England and Scotland. Personal care was to be accorded the same importance and status as health care, free at the point of use and paid for out of government expenditure. The National Care Service, like the NHS, was to be not for profit and private providers were to be gradually absorbed into the new system.

These proposals transformed Brown’s idea for a National Care Service, which depended on a specific funding mechanism like insurance being developed and gave private providers the key role in delivering care. Since then, Keir Starmer has been remarkably silent, given how the Covid-19 crisis has exposed the flaws in the care current system as never before.

Unison’s vision for social care

It was within this context and following the experience of the Corona crisis that Unison launched a report last week calling for a National Care Service. The report is extremely welcome and worth reading, promoting the need for an alternative at a time when the general population has become highly aware of the failings of our current system.

As you might expect, coming from Unison, the five interim measures it recommends focus on the needs of the workforce. Three directly cover staff issues: pay and conditions, training and professionalism and workforce strategy. The other two, funding and the impact of outsourcing on the workforce, indirectly impact on the workforce.

The report was written from a UK perspective and the position of the social care sector in Scotland is, in certain respects, slightly better than in England. The fundamental issues, however, are similar and Scottish Unison has called for the for the recommendations to be introduced, saying:

Coronavirus hasn’t broken our care  home system. The system was broken and not fit for the purposes of providing an essential public service. What the needless loss of life in care homes has done is made an already existing crisis too obvious to ignore.”

So, how might the recommendations apply to Scotland and what could the Scottish Government do to implement them here?

A fully funded service

Unison quote from the House of Lords Economic Affairs Committee report last year entitled “Social care funding; time to end the national scandal”. The title speaks volumes. The report estimated that £8 billion was needed immediately in England just to bring services back to 2010 levels.

Scotland would benefit from a similar report, one that cuts through the official narrative. This claims budgets have increased year by year and that if only resources could be transferred from hospitals to the community and savings realised, then all needs could be managed. Covid-19 has destroyed the foundations for those claims.

Almost the first response of the Scottish Government to Covid-19 was to spend £43 million on the temporary Louisa Jordan hospital; that was needed to compensate for all the cuts in acute places. On the social care side, no less than 1,400 older people were stuck in hospital when the virus struck due to lack of funding for care. It was the decision to fund their discharge which appears partly responsible for the disastrous spread of Covid-19 into care homes.

While the Scottish Government and Parliament have both ostensibly been more sympathetic to the need for funding than in England, the relentless austerity of the last ten years has exacted a terrible toll. Scotland may have avoided the situation that Unison reports in England, where there were 30 councils in January 2020 paying less than £500 per week for an older person in a residential care home (in Scotland the minimum rate is £614.07), but many services have disappeared and those that remain are grossly underfunded. Staff then bear the brunt of this, while services fail to deliver their intended outcomes.

The latest illustration of this is the epidemic of loneliness among older people in Scotland, caused in part by cuts to “non-essential” community services like lunch clubs and day centres.

Not for profit

“Over half of Scotland’s care homes are run directly for profit – often by big businesses who base themselves in tax havens. People expect public money to be spent providing care in their communities – not to be funnelled into offshore bank accounts” (Unison Scotland).

The Unison report doesn’t include this as a short-term measure, rather a longer-term aspiration – but unless the issue is tackled its difficult to see how the other measures Unison recommends can be achieved.

In the care home sector about 12 per cent of fees are extracted as profit. If that money was re-invested in care, a significant part of the funding shortfall for the care home sector could be met. We could address this in Scotland if the Scottish Parliament used its regulatory powers to require all care services to be not for profit and stopped money leaking out of the system.  The Scottish Government has already promised to do this for children’s services.

To stop the leakage, a new way also has to be found to fund buildings. By far the largest amount of profit in the care home sector is extracted through the buildings, not the care. Care Homes remain highly profitable while, as the Unison report points out, home care providers are folding. This is a similar problem to the notorious Private Finance Initiative and its successors which drain money out of the NHS. Similar too to the way some housing associations have borrowed on the open market and why much of the rent on some tenants now goes in meeting interest payments. Given the will, the new Scottish National Investment Bank could address these issues if its focus was to change from promoting private sector investment to supporting the public sector.

Pay and conditions

In Scotland there has been a determined attempt to get social care providers to pay the real Living Wage – currently £9.30 an hour – through making this a contractual requirement for the provision of services. That amount remains woefully inadequate recompense for what is a highly demanding job. It reflects the lack of value that is placed on caring roles which are predominantly filled by women. It leaves the social care workforce paid less than most supermarket staff and has failed to address the labour shortages

Any beneficial impacts of the Scottish Living Wage have also been partially offset by the Scottish Government’s failure to tackle other elements of pay and conditions of people working in the social care sector. The Unison Reports highlights some of these, including the absence of sick pay, the failure to pay staff properly for ‘sleepovers’ and travel time in home care services. There are many others, such as providers expecting staff to do training in their own time and low pay differentials even for the most experienced of carers.  There are no paths to career progression.

The parlous conditions of the workforce was demonstrated on 24 May, when the Scottish Government was forced to introduce a special hardship fund for social care workers. This was to ensure that staff who followed guidance and isolated on public health grounds would not be left without any income at all.  There remain another dozen gaps that could be addressed if the workforce was brought back into the public sector.

Professionalism and training of the workforce

Unlike in England, all people working in social care now need to register with the Scottish Social Services Council.  New front-line care workers, however, have six months to register and then five years after that to obtain the relevant Scottish Vocational Qualification. By which time the majority will have left, such is the turnover in the workforce. To make matters worse, much training in any case has now been reduced to online tick-box exercises. 

In social care there is no equivalent to the induction standards for Health Care Assistants, the unqualified staff in the NHS. A national programme of mandatory training and support, such as that which has started to evolve for infection control during the corona crisis, is an area where a National Care Service would make an immediate difference.

Workforce Planning

Once more in Scotland, unlike in England, workforce planning has been developed over a number of years with a view to ensuring that there are as many doctors, nurses and social care staff as we need.  In December 2019 the Scottish Government published what it described as an ‘Integrated Health and Social Care Workforce Plan’. Unfortunately, it contains no plan for frontline care staff because “At national level the Scottish Government has very limited control over the supply pipeline for social care workers”. That is not true. 

The Scottish Government has the power to set up training programmes for social care workers and determine wage levels just as it does with the NHS. The problem is the Scottish Government is still looking to the market to address workforce issues despite all the evidence that the market has failed.


“The aspiration over time should be to deliver the vast majority of social care through public funding, and to substantially increase the direct public provision of social care. This would begin to remove some of the differences in service quality between NHS and social care services, and would address the glaring inequality around access to care that is built into the current care system”.

Unison has shifted its position from promoting ethical commissioning or outsourcing of services, to concluding that services would be better run and better joined up if operated in-house. In Scotland, the Health and Care Partnerships were intended to join up a fragmented system. But while bringing professional working in the community, from GPs to social workers, under single management that has done nothing to bridge the gaps with outsourced services. The corona crisis has shown that all too clearly.

The advantages of one National Care Service aligned with the NHS would be considerable.  For example, it could not only train staff to work in hospitals, the community or care homes but empower staff to move between them, on the same wage scales and the same pension rights.  Instead of providers competing with the NHS for scarce staff, resources could be planned and deployed where most needed.  While there is a wide range of skill sets for non-professionally qualified staff across health and social care, at one extreme ‘technical’ at the other ‘person-centred’, if the Corona crisis has shown anything it’s that we need to combine these in the care we provide for the frailest older people. Residents in care homes needed staff with the know-how to protect them against infection and to respect their rights.

Where next?

Unison’s report and list of interim measures provides a good starting point for a debate about a national care service for Scotland.  Such a debate, though, will also need to consider other questions, such as:

  • how do we reinstate a public service ethos in the management of social care services in Scotland?
  • how do we make services accountable to the people that use them?
  • how do we design services that support carers and interface effectively with community based supports?

Picture courtesy of WorldSkills UK