Nick Kempe: The Feeley review on Adult Social Care offers only more of the same

“People in Scotland deserve far better, but we will not get that so long as those responsible for the current system are responsible for redesigning it.”

CUT THE VERBIAGE and the recommendations of the ‘Independent’ Review into Adult Social Care which were published on Wednesday may do little other than perpetuate the current system, which failed so badly during the Covid crisis and which so many people in Scotland wish to see reformed -a system in which caring for people has become almost impossible.

Worse, if implemented, the recommendations will result in further centralised control and top-down management ‘solutions’ being imposed on staff who need the opposite – time to care. The recommendations, disguised as heralding a National Care Service, need to be seen for what they are – an attempted power grab by central government and a further assault on local democracy.

The reasoning in the report, produced by Derek Feeley, former Director General for Health and Care at the Scottish Government and recently returned from the US where he was Chief Executive Officer of the Institute of Health Improvement, is incoherent from the start:

“I want to be absolutely clear from the outset that there is much about adult social care support in Scotland that is ground-breaking and worthy of celebration. The introduction of self-directed support, the integration of health and social care, and the promise of the Carers Act form the scaffolding upon which to build.

“And yet, the story of adult social care support in Scotland is one of unrealised potential. There is a gap, sometimes a chasm, between the intent of that ground-breaking legislation and the lived experience of people who need support. In the improvement world, there is a maxim which reads something like “every system is perfectly designed to get the results it gets”. That is the basic challenge for us. We have inherited a system that gets unwarranted local variation, crisis intervention, a focus on inputs, a reliance on the market, and an undervalued workforce. If we want a different set of results, we need a different system”

In the recommendations that follow, Feeley retains the failed “scaffolding”, for which he bears a large degree of responsibility, under the cover of a new National Care Service (NCS). Having acknowledged every system is designed “to get the results it gets”, rather than tackle the deep structural failings in adult social care, Mr Feeley who doesn’t like local variation, falls back on trying to improve it. This is the same public service improvement agenda – of trying to do more with less and make the private sector work – that has been tried for twenty years now, first by new Labour/Liberal, then by SNP governments in Scotland. It has failed, but Mr Feeley is so completely embedded in that system that he cannot see a way out of it or the contradictions in what he writes. 

The Feeley Review provides no analysis of the failings of the current care system, which in the last couple of months has failed to prevent Scotland’s drug deaths reach record highs, seen numbers of suicides increase and resulted in homeless families being stuck in unsuitable bed and breakfasts for months on end.

The Covid crisis is glossed over and the implications ignored. What happened at Home Farm Care Home in Skye is used not to illustrate what is wrong with the private sector but rather to argue that we cannot afford to nationalise the care home industry. The impact of the fragmentation of the care system between adults, children and criminal justice and consideration of what to do about this is simply avoided. The reasons for the failures of primary health care provision during the first wave of the Covid crisis, whether to people living in care homes or in community, are not discussed. 

Having said that we need to get away from the current system in which social workers are forced to act as gatekeepers, the report advocates continuation of the self-directed support system under which:

A network of support and brokerage services is in place in parts of Scotland that can help people prepare for assessment, including identifying what goals or outcomes people want to achieve with support.”

If the intention of the report really was to remove eligibility criteria and free up social workers to do the job they were trained for, there would be no need for anyone to “prepare for assessment”.

Last week, the Common Weal’s Care Reform Group (which I convene) published a Manifesto for a National Care Service. We explained the meaning of care, proposed that the primary aim of a National Care Service should be “to promote a caring society and to support and provide care to all who need it, free at the point of use”, set out a number of subsidiary objectives, and alongside that a number of principles on which such a service should be founded.  You may agree or disagree with what we wrote – part of the point of manifestos is to promote debate – but you will find no such set of aims, objectives or principles in Derek Feeley’s report.

Indeed, the Report fails even to consider what is meant by care, but instead starts with “adult social care supports”. While there is a token acknowledgement of the importance of relationships, which were central to the recommendations of the Independent Care Review for children, the whole report is framed in terms of individual rights to care provision. That sounds good but is fraught with difficulties.

For example, there is a recommendation that “carers should be given a right to respite”. How this fits with the rights of the person needing care to refuse respite is not explained. I still vividly recall working with a family on this very issue 30 years ago. Over 18 months we considered a whole range of compromises, but I am afraid that it was only when the old man passed away that the issue of how to resolve differing needs within a caring relationship was resolved.  Social work and care, which are both about relationships, are like that, complex, often messy, and take lots of time. 

The Feeley Report fails to recognise this and it has serious consequences. Instead of freeing up staff to do care properly and allowing care to be designed from the bottom up, as the Common Weal Manifesto advocates, they propose that the provision of social care supports be improved from the top down.

Responsibility for care provision is to transferred from local authorities, who are still democratically accountable and do represent their local communities, to a new Minister for Care – a junior role, rather than a separate Cabinet Secretary with equal status to the Cabinet Secretary for health. That Minister will then, under the proposals, be responsible for driving “science based improvement methods” in care provision across Scotland through the Health and Social Care Partnerships (HSCPs).  This is the same disastrous model of centralised control that drove Health Boards to discharge older people to care homes, whether or not tested or infected with Covid-19. 

Instead of diversity to fit local circumstances, the model of centrally decided improvement programmes that has been applied to the NHS is now to be applied to social care. In doing so the difference between health treatment, where science and rigorous systems have led to improved outcomes, and care, which is based on more practical/moral and relational ways of working, is totally ignored. The report is silent too on the adverse consequences of this top-down approach to improvement for staff in the NHS. The Sturrock report into NHS Highland found that some staff attributed bullying to the imposition of the Patient Safety Programme which Derek Feeley has been very much involved in promoting. 

The building block for Feeley’s new NCS are the HSCPs, set up to integrate Care with Health. In 2018/19, these spent just £3.8 million on social care compared to £6.1 billion on primary health care services. The new NCS will, despite the name, be nothing of the sort, it will be treated as an adjunct of the NHS. This is reflected in the structural proposals, with Health Boards still nominating onto the local NCS Board and the Chief Executive of the NHS being on the national board of the NCS. Token representation of staff, service users and carers on the various boards will not compensate for the loss of democracy and increased centralisation. Instead, the reforms proposed for HSCPs will give them responsibility for commissioning services, including from local authorities.

This is the realisation of Thatcher’s dream, the purchaser/provider split where the NCS, unlike the NHS, provides no services directly. It is not difficult to foresee the consequences. The remaining local authority services, which pay staff a decent wage, will under budgetary pressures become unaffordable.

This is disguised because in the report, Feeley makes all the right noises about the importance of the workforce and how they have been mistreated. While endorsing the recommendations of the Fair Work Convention,  published two years ago but still not enacted, and the trade unions’ call for national collective bargaining, the report contains no proposals to increase wages. That is despite the welcome recognition that paying for care should not be seen as a cost but an investment that has much wider benefits for the economy.

If the report cannot recommend a decent wage rise after Covid – Common Weal believes all care staff should have their wages uprated to local authority levels – it is not difficult to foresee the consequences. Instead of a fair wage, the trade unions will end up trying to haggle a 0.5 per cent increase here or slightly better terms there, in the face of ongoing budgetary constraints.

Curtailed public expenditure and the promotion of the private market at the expense of the public interest are central to understanding both the failures in the care system and the Feeley Review.  The important thing to realise is that the eye-catching financial proposals in the report are relatively cheap to deliver: £51 million to abolish “non-residential charges”; £116 million to provide middle class self-funders in care homes an equivalent level of financial support to those who are “fully” publicly funded; £32 million to re-open the Independent Living Fund for people with complex disabilities. All good proposals but a small price to pay for keeping the current system going after the catastrophe of the last year.  

The true cost of expanding “access to support including for lower level needs and preventive community support” is not calculated. Instead, £436 million is the amount estimated as required to restore care expenditure in 2018/19 to 2009/10 levels. How this fits with the excellent submission from Social Work Scotland to the Review that £700 million would be needed just to restore adult social care expenditure to pre-austerity levels is not explained. The question of whether care in 2009/10 was adequate – it wasn’t – or what it would cost to deliver the many worthy aspirations in the report is simply ignored. 

The areas where the report identifies potential savings that could help pay for the recommendations, notably delayed discharges and “unnecessary” hospital admissions, have been around for over 20 years. All the report can suggest is we continue to flog a dead horse. After the Covid crisis it should be obvious that the NHS, like social care, needs more resources, more beds, not less, to cope with the pandemics which will inevitably hit us in future.

Given that the existing system has so little capacity to make savings, it is extraordinary the report fails to tackle the legalised extortion of the care home sector.  The reason for this? “Our principle (sic) concern is not with profit itself, which plays an important function in any market economy, but with what we have come to think of as “leakage” from the care system in Scotland.”

While recognising thatsignificant sums leave the care economy”, Feeley’s answer to this is financial transparency – a covenant with the sector to restore “trust” and better contractual arrangements. No local authority contracts officer in the world is going to be able to keep up and beat the accountants and lawyers whose job it is to siphon money into tax havens. It will be difficult enough, and require significant extra resources, simply to ensure that providers don’t hike their care fees to snaffle the extra £116 million given to self-funders for free personal care.

Feeley’s justification for ignoring the many calls he heard for nationalisation of the sector is that it might cost £2 billion. Even if one accepts that amount (which we in Common Weal don’t) with something like £100 million leaking out of the sector each year, it should be quite affordable. A National Care Home buy-out fund, paying 3 per cent interest per year – instead of the 10 per cent extracted by providers – would be very popular with older people whose money is languishing in bank accounts and building societies that pay no interest.

Feeley’s case for a National Care Service makes sorry reading:

“We need a National Care Service to achieve the consistency that people deserve, to drive national improvements where they are required, to ensure strategic integration with the National Health Service, to set national standards, terms and conditions, and to bring national oversight and accountability to a vital part of Scotland’s social fabric.”

In advocating this the Review ignores “the most frequently mentioned concern [about an NCS which] was that it would bring loss of local knowledge and expertise. Many people said they thought a better mix of national and local responsibilities and activities was needed”. It also ducks central government’s responsibility for failing to fund local authorities properly and the consequences that has had.

People in Scotland deserve far better, but we will not get that so long as those responsible for the current system are responsible for redesigning it.

Picture courtesy of WorldSkills UK