Is Scotland's National Care Service at a crossroads, or a dead end?

The SNP Government insists that the legislation to create the NCS is simply "paused" while ministers and civil servants go back to the drawing board to consider the criticism raised by trade unions, Cosla, councils, and political opponents who have withdrawn their support for the current Bill like a string of dominoes in recent months.

Back in September 2021, when then-First Minister Nicola Sturgeon pledged that the new care service would be "operational" by the end of the parliamentary term in 2026, she described it as "arguably the most significant public service reform since the creation of the National Health Service".

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She conceded that such massive reform would inevitably come with fierce debate, but that it was "vital that we get this right".

More than three years on, Ms Sturgeon has exited stage left, Scotland is on its third Cabinet Secretary for Health and Social Care in as many years, and the vision of a care service lies in tatters.

The day after the Scottish Government confirmed that the NCS Bill was being delayed, I happened to be chairing Scottish Care's annual conference at the Glasgow Hilton hotel.

The mood music from the hundreds of delegates in the room - representing care homes, home care providers, regulators, and other social care-related organisations - was not optimistic.

Asked whether they still believed an NCS would ever materialise, in any form, a sea of red and amber cards were held aloft indicating 'No' or 'Maybe'. Green ('Yes') cards were entirely absent.

Current Health Secretary Neil Gray insisted the Government remains "absolutely committed" to it; his fellow panellists (from the Scottish Greens, Labour, and Conservatives) were, to put it mildly, sceptical. 

 

From the beginning, the idea of a care service has been beset by confusion.

Ms Sturgeon's decision at the outset to invoke comparisons with the NHS has not helped in terms of public understanding.

Crucially, this was never a reform that was going to make social care "free at the point of delivery", with all care home fees abolished.

Nor was it going to iron out the discrepancy that sees self-funding care home residents charged considerably higher fees than those whose place is paid for by the council.

On average, as of March 2023, a self-funding resident with nursing care was paying £1,328 per week compared to the £910 per week levied on local authorities for each council-funded resident.

Charges for self-funding care home residents are rising much faster compared to those whose care is paid for by their local authority (Image: PublicHealthScotland - Care Homes Census 2023) This gulf has widened significantly since 2014 as people with capital worth in excess of (currently) £21,500 have had to shoulder a larger burden of the cost of social care as austerity and inflation has eaten into local government budgets.

Nor was an NCS ever going to mean stripping the private sector out of social care provision.

A paper published in the BMJ on November 14 concluded that outsourcing social care in England to the private sector - which has increased rapidly, UK-wide, since the 1980s - "has led to worse care and should be rolled back".

Competition was supposed to provide more efficient services, but instead the profit motive had fostered lower staffing rates and poorer outcomes during the pandemic, said the researchers, pointing to evidence from England, Canada and the US that "on average, more residents died after outbreaks which occurred in for-profit care homes than after those in public and third sector home".

Their recommendations included profit caps, limiting the payment of shareholder dividends, and restricting offshore and private equity investment and ownership.

Since March, a private jet, two yachts, and £500,000 in designer watches have been seized as part of an ongoing £76 million fraud investigation into the Carlauren Group, which purchased 23 properties across the UK to turn into "luxury" care homes before going into administration in November 2019.

Most care homes in Scotland are privately-run (Image: PHS) This is the sort of thing which makes the general public highly suspicious about the benefits of mixing private equity and social care, although - to be fair - many care providers in Scotland are small to medium businesses struggling to make ends meet as overheads spiral.

They are certainly not "rolling in it".

It is also hard to imagine how the public purse, in its straitened state, could ever fill the gap by taking over the cost of running and maintaining premises and employing staff.

In Scotland, 65% of care homes are run by private operators, 22% by charities, and 13% by local authorities or the NHS.

So if the NCS was never really about an "NHS for social care", what was it about? And what might it still achieve, with some £28m already invested in its reforms?

In her statement to parliament on Thursday, Social Care Minister Maree Todd said "unacceptable variation" in care, including rates of delayed discharge from hospital - a symptom of social care shortages - up to ten times higher in some areas than others, was "clearly unfair".

Australian Prime Minister Scott Morrison delivers the Royal Commission Report into Aged Care during a press conference on March 1, 2021 in Sydney, AustraliaAustralian Prime Minister and Liberal Party leader Scott Morrison delivers the Royal Commission Report into Aged Care during a press conference on March 1, 2021 in Sydney, Australia. It is being implemented by his successor as PM, Labour Party leader Anthony Albanese (Image: Getty Images) The vision remains some form of standardisation.

A factsheet published by the Scottish Government in June describes how the NCS will "tackle the unwarranted variation of care across the country and drive up quality" by providing "greater consistency" through the creation of "national standards".

Exactly what that means - in terms of staff pay and conditions, people's ability to access care, and how much they pay for it - remains unclear.

Meanwhile, Australia is in the process of rolling out what has been hailed as the "greatest improvement to aged care in 30 years" following the passing of its Aged Care Act in 2023.

An "eye-watering" $5.6 billion (£2.9bn) package of investment - including $4.3bn (£2.2bn) in extra support for people who remain in their own homes - will be bolstered by larger means-tested contributions for new care home residents.

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Additionally, Australians using the Support At Home service will pay a percentage of their non-clinical social care costs depending on income and assets, up to a lifetime maximum of $130,000 (£67,000).

In Scotland, meanwhile, care at home remains wholly council-funded.

St Vincent's Care Services, Australia's largest not-for-profit aged care provider, said the new system "will raise standards and ensure the system can be adequately funded".

How was this reform agreed? Mainly, through cross-party cooperation to implement the recommendations of 2021's Royal Commission into Aged Care.

There's a lesson for Scotland in there somewhere.