Earlier this week, the Scottish government published some landmark legislation to support its vision of social care reform. By shifting responsibility for care services from local authorities to Scottish government ministers by 2026, this Bill heralds a radical change in the way that social care is organised in the country and marks a further divergence in approach between Scotland and its closest neighbours.
Under these reforms, a new national body within the Scottish government – the National Care Service – will set standards and commissioning priorities for delivery by newly established local care boards. Although the legislation lays down a framework for reform, there is still much to be decided about what the National Care Service will look like and this will be determined through an intensive co-design process over the next year.
As all the other UK countries grapple with common challenges, and also embark on their own social care reform agendas over coming years, there will be a great deal of interest in how Scotland’s approach is unfolding. In this explainer, we explore exactly what the National Care Service is intended to do, what it is not, and key questions other countries will want to pay particular attention to as reforms are implemented.
What are the problems the NCS Bill intends to solve?
The Independent Review of Adult Social Care, published last year, outlined significant challenges in the Scottish social care system. In particular, the review questioned the effectiveness of local authorities’ commissioning practices and their ability to shape a market that is responsive to people’s wants and needs; a lack of consistency in access; and limited collaborative and strategic leadership.
The Scottish government, in response, proposed the creation of a new national body called the National Care Service (NCS), intended to drive consistency and quality by setting a vision, standards and direction for the social care system at a national level. In so doing, the plans will take away responsibility for social care from local authorities and give national government ministers direct accountability instead.
Alongside its role in setting commissioning priorities at a national level, the NCS is also intended to support the delivery of the Fair Work convention that aims to improve the terms, conditions, and pay for the workforce in Scotland.
At a local level, care boards will replace the existing integration authorities (which share similarities with England’s soon-to-be-established integrated care boards) to shape and deliver care in line with the vision set by the NCS. Care boards will be established and scrutinised by ministers and cover all community health and social care services, with the intention of aiding better integration. The membership of the care boards is yet to be decided, but the plans state that members will be appointed by Scottish ministers.
The NCS Bill is intended to mark a shift in the narrative around social care, making a commitment to placing human rights at the heart of services and framing social care as an investment, rather than a burden. The introduction of rights to breaks for unpaid carers and visits to or by people living in care homes also have the potential to make a difference to many people who draw on care and support and their carers.
What is it not?
Although the name evokes some similarity with the NHS, the NCS refers to a new structural entity with a range of new duties and does not (as may be assumed from the language) represent a new care service free at the point of use. The Bill clearly signals further rounds of secondary legislation that may make changes to eligibility and charging, but at present there is no indication of changes to current arrangements. Personal and nursing care will remain free as they have been in Scotland since 2001, and a means test will continue to apply for all other services.
The NCS will, however, resemble the structural arrangements of the Scottish NHS more closely, with an executive agency run by civil servants and reporting to Scottish ministers.
Key issues to face
There are a number of complexities that Scotland now faces in navigating this new path, and stakeholders across other countries will be keeping a close eye on developments. Elements that all will be following closely include:
1. Will a shift of accountability from local to national government deliver tangible change?
Establishing the NCS offers potential to increase the visibility of social care and give it equal weighting with health in the political agenda. Redefining accountability around ministers could also potentially help in times of crisis such as Covid-19 – a point that England will want to note as coordination and consistency of response was hampered by unclear accountability.
But there could also be significant risks to shifting accountability away from local areas. Knowledge of local dynamics, local democratic accountability and proximity to people all play a role in shaping a care offer that is responsive to people and their communities. A key test of the NCS will be to assess whether this change in accountability arrangements will make a tangible difference to the quality of care people experience, to achieve the aspirations set out in the legislation to create a vibrant, consistent and responsive social care system.
2. Will the NCS deliver consistency and better quality in social care services?
Having a national agency that can set quality standards, foster better coordination across different social care organisations, and drive commissioning practices could well address some of the consistency issues highlighted by the Independent Review. Scotland has a history of setting some social care policies at a national level and it will want to learn from that experience. Under its National Care Home Contract, for instance, commissioners and providers of care agree a national minimum costs for care homes. This national approach has brought benefits of stability and some consistency, although different parties have often disagreed over the true cost of arranging care and it has not experienced a completely smooth implementation.
Any attempt to define consistency across the country will need to be balanced with the need for local flexibility. Too rigid an approach risks stifling innovation and hampering responsiveness. Scotland is also a hugely varied country and different local areas have different needs and dynamics. Our research into the systems of Germany and Japan suggests there is a delicate balance to be struck between national stability and local flexibility.
3. Will it solve the workforce issues?
Recruiting and retaining social care staff is the most pressing issue across the UK’s social care systems at the moment, with considerable impacts on the ability of systems to respond to growing demand and to maintain good quality services. The national oversight afforded by the NCS to drive the implementation of the Fair Work convention has the potential to drive better pay and conditions for the social care workforce. But any work to improve conditions for care staff will also need to be sensitive to local pressures, such as travel times and local employment markets, to ensure the aspirations of Fair Work can be fully met. Crucially, adequate funding will be essential to delivering on promises to increase pay in the sector. Special attention will also need to be given to retaining and supporting the social work workforce, who are currently embedded within local authorities and who are key to engaging with people and undertaking care assessments.
4. What does this all mean for health and care integration?
The new care boards are designed to deliver better integration between community health and social care. There are many questions around what this means for health (and particularly the acute sector) now that integration is realigned around the community. Particular attention will need to be given to whether this will have an impact on quality of care for people, and what the implications are for those being discharged from hospital. Questions remain on the detail of how integration authorities will be replaced by care boards, including how they will be funded and staffed, and the balance of representation between health and social care. It is essential that bringing together community health and social care more closely encourages rather than loses closeness with other services key to good care for people, such as housing.
5. How much will the changes cost?
The costs of these provisions presented within the bill are estimated to total around £0.5 billion by 2026/27. However, estimates of how much will be needed to fund the policy vary: the Independent Review estimated costs to be around £0.66 billion, but others such as the Convention of Scottish Local Authorities place full implementation costs at around £1.5 billion. How funds are raised, the size of the envelope, and how they are allocated will determine how successful the National Care Service can be.
First steps and many unknowns
The Bill sets Scotland on its path to creating new social care structures, but there remain many unknowns at this stage. As it stands, the legislation introduces a structural reorganisation and that, alone, is unlikely to deliver tangible change to what people experience in their everyday lives. The plans have not been universally received in a positive light across the Scottish political spectrum, with critics fearing “over-centralisation” of social care, and too heavy a focus on bureaucracy. Others have been more welcoming of an opportunity to end the “postcode lottery” in social care.
Whether or not the reforms successfully address the problems identified in the system will depend on the action – the promised co-design and secondary legislation – that is taken over the coming years. Whether or not the financial envelope is also sufficient to both implement the changes and keep pace with demand is another source of uncertainty.
Evidence of decades of structural reorganisations suggests these can sometimes be a distraction from the problems at play currently, and offer limited improvements to the problems they were trying to solve. Keeping people at the centre of ambitions, and addressing current issues, will be essential to how much a National Care Service can achieve. The stated intention to involve people and carers through co-design offers an opportunity to place them at the centre of these reforms.
As England embarks on its own programme of reforms to social care and integrated care boards take effect, and Wales and Northern Ireland consider the outcomes of their respective consultations, each country will want to keep a very close eye on developments in Scotland and seek to learn as it takes its first steps on this potentially radical journey.