The space between chaos and shape

[Originally written by Annie Gunner Logan for the Social Care Future blog and reproduced here.]

Scotland stands at a crossroads.

Now you could be forgiven for thinking that I’m about embark on a discussion of the constitutional question which has dominated Scottish politics for more than a decade. And it’s certainly true that the upcoming election here as is critical as any since 1999.

But that’s not my subject here. I’m talking about the opportunity we have to change the future of social care in Scotland.

That opportunity has arrived not a moment too soon. The phrase ‘social care commissioning is broken’ has become a cliché, but it’s no less true for that. Money – or the lack of it – has played its part. But the fracturing has been much deeper. As the architecture of adult social care has become ever more complex – we have lost sight of what it is actually for.

And that brokenness has had real human consequences for those who work on the frontline of social care, and most profoundly for the people they support. The pandemic has only served to expose this and make the case for change more urgent. It has also raised the stakes. We can no more tinker at the edges than we can wait.

None of this is unique to Scotland, of course. Social care is one of the wicked problems of our age. But what is particular to Scotland is that we have been presented with a chance to fix it. That chance has come in the shape of the report of the Independent Review of Adult Social Care in Scotland – a review commissioned on the back of, but still in the grip of, the pandemic.

There were plenty who doubted that it would be possible to produce to something meaningful in so short a space of time – hands up, I was among them. But when it arrived, the report of the review team led by Derek Feeley did not disappoint. It runs to 109 pages, has 53 recommendations, and is built on three core propositions – shifting the paradigm, strengthening the foundations, and redesigning the system.

Of course, it’s not perfect. There are gaps to be filled, dots to be joined up and expectations to be managed. Several things are especially worth underlining. Social care is not an island and it cannot change lives on its own. The structural disadvantage faced by many people who rely on support requires whole system change.

The vision of social care captured by the review is a huge step forward, but more work is needed on its relationship with housing support and criminal justice. More thought too needs to be given to its digital and data dimensions. And how the changes proposed will work in tandem with work already underway on redesigning the care system for children and young people – the implementation of The Promise – requires careful thought.

But notwithstanding all that, the sheer scale of engagement upon which the Review’s findings are predicated is impressive – 228 submissions, 13 events, 128 meetings – in just three months. Its most significant achievement by far is its transformation of Scotland’s social care narrative. It really does feel as though we have turned a corner. That narrative – for all its rich, mission driven history in the third sector – had fallen on stony ground in recent years.

The Review has reminded us – in crystal clear terms – why social care matters and what it should, and could, look like. ‘Strong and effective social care support is foundational to the flourishing of everyone in Scotland’ – not merely a place where services are provided but a vehicle for independent living, delivered through collaboration not competition.

There are very strong resonances here with the work led by Social Care Futures – which the Review Chair and his team, I have no doubt, studied carefully.

This is no small matter. In the increasingly corrosive world of commissioning, reminding folk of social care’s purpose has too often felt like pushing a rock up a hill. Now we find ourselves at the summit – and the view looks better than even we might have hoped for. We can turn our attention at last to the how rather than the what.

On that score too, the Review has also been true to its brief in setting out the basis of a new architecture to support social care, the National Care Service. It has started – but not finished – describing what such a service could look like. At CCPS (Coalition of Care and Support Providers in Scotland) we have given that vision a broad thumbs-up. Not because it is flawless – but because we think that with application and initiative it can succeed.

Others – notably some political parties and COSLA (Convention of Scottish Local Authorities) – have been more sceptical. At CCPS we had some misgivings about the task given to the Review team and not least to the term, ‘National Care Service’. Taken together and separately, those words did not capture our vision. We were particularly suspicious of one version which featured significantly in the discourse, a ‘nationalised’ care service – state run, state delivered – the National Health Service Mark II.

From our perspective this was not the solution – but not because it would undermine the fabric and fortunes of third sector organisations. We do not want this to be a turf war based on institutional self-interest. If there was a better way of delivering for our beneficiaries than furthering our existence, we would have a responsibility to say so – to call ourselves out.

Our objection to nationalisation is based on what we know from decades of providing social care support. All our experience tells us that a purely state-run system doesn’t lend itself to providing the kind of support that people actually want in a way that suits their needs. It’s very positive that the model recommended by the Review team avoids that pitfall, but we also accept there remain significant challenges to be explored and resolved. And, as the report acknowledges, when that’s done, we will still need to find a way to pay for it all.

In short, the Review advocates a National Care Service, established in statute, on an equal footing with the National Health Service. If enacted, accountability would shift from local government to Scottish Ministers via a Chief Executive and multi-partner board. It would oversee local commissioning and procurement of social care and support by reformed Integration Joint Boards (responsible for the integration of adult health and social care services in Scotland), with services provided by local authorities and third & independent sector providers.

It is not hard to see why local authorities in particular, are unnerved. Implementing the Review’s recommendations will mean change – a significant shift in agency and power. For third sector providers on the other hand, the recommendations offer the opportunity for a long overdue levelling up and the prospect, finally, of an end to an inequitable two-tier workforce.

But framing this opportunity as a threat to local democracy misses the point and poses the wrong question. The most important factor in redesigning the system must be about how the delivery of social care support can also be made accountable to those who receive it. This is about how the principles of Self-Directed Support – enshrined in legislation since 2013 – and the Christie Commission – published in 2011 – can finally be put into practice.

From where CCPS sits, a national service with local decision making is possible. And we have already published some Big Ideas about commissioning and procurement which can make it work, setting out for key tests for change – Does it shift power? Does it increase choice and control? Does it improve accountability and transparency? Does it improve sustainability?

Local authorities can still play a central role in facilitating accountability. But they should no longer be the gatekeepers. And because local communities are not homogenous, real accountability must be granular, focused on and connected to the people who actually use the service.

So the biggest question to be answered as the Review moves into the implementation phase will be how to combine the envisaged model of national accountability with local variation, flexibility and responsiveness. That phase will not begin in earnest until after the upcoming election when the necessary legislation is drafted. But our own agenda, to work in partnership with others to influence the shape of things to come, begins now.

With ingenuity and creativity – and in collaboration with stakeholders across the public and third sectors – we can ensure that co-design is at the heart both of the implementation process and of the system which emerges from it. One thing is certain – the status quo is not an option. And as the Review itself concludes – ‘If not now, when? If not this way, how? And if not us – who?’