‘Co-designing the National Care Service: aspiration rather than reality?’

ALLIANCE Chief Officer, Sara Redmond, reflects on the co-design process of the National Care Service.

As we approach the half-way mark in this Scottish Parliament term it is worth taking stock of progress towards the proposed National Care Service (NCS). Arising from the Independent Review of Adult Social Care (or Feeley Review), the NCS is intended to transform delivery of social care through national standards and oversight, embedding human rights, and further integrating community health and social care. Described as “the biggest public sector reform in Scotland since devolution”, the bill to establish the NCS has been on pause for months to allow further progress on the co-design process and to attempt to build greater consensus.  

The need for consensus building was heightened by what looked set to be a showdown between the Scottish Government and the Convention of Scottish Local Authorities (COSLA) over the NCS. With social care traditionally within the local government remit, COSLA were initially unconvinced by the bill as put forward by the Scottish Government. Reaching a consensus position between the two layers of government was clearly a priority, and over the summer they reached an agreementⁱ on shared accountability arrangements, alongside NHS boards, for the NCS. This would see local government continuing to be responsible for the staff, assets and delivery of social care. 

Yet we have heard over the years that many of the people with experience of accessing social care or providing unpaid care have felt let down and unheard by the current accountability arrangementsⁱⁱ. Making the decision to retain a central role for local government in the NCS outwith the co-design process has, understandably, deeply concerned the very people who the service is meant to be designed by and for and risks breaking trust in the process. That is certainly not to say there is nothing positive about local government’s record in delivering social care, or to criticise the dedicated, caring workforce. 

Instead, it highlights a failure to live up to the Scottish Government’s stated aspirations on co-design and the central role people with lived experience of accessing social care would have. Whilst we recognise that cooperation with local government was always going to be necessary to deliver the NCS, did this decision really have to be taken by two layers of government behind closed doors the way it was? Could it not have directly involved the people it will affect? If given the time, information and space to consider the options, it’s possible the co-design process would have reached the same point, but with much greater legitimacy. 

The agreement with COSLA represents the biggest gap between aspiration and reality on co-design, but not the only one. Whilst the Scottish Government were at pains to point out that a final decision hasn’t been made on exact makeup, the ALLIANCE were especially taken aback to see the proposals for an NCS National Board. In particular the initial absence of any third sector representation on the board, despite the significant role the sector plays in community health and social care delivery and in the preventative support highlighted in the IRASC report, seemed like a glaring omission. And again, where was the role for co-design in the decision behind this announcement? 

Overall, we are concerned that far from being a meaningful process of co-design, the Scottish Government are engaged in a process of consultation. More in-depth than a normal consultation, and with far greater resources deployed, but consultation nonetheless. For the NCS to truly deliver the improvements in social care and accelerate the efforts towards greater integrated health and social care we desperately need, people have to be able to feel they have genuinely shaped it, rather than simply agreed to one model or another put together by others and taken to them for approval. 

Beyond the co-design process, significant questions remain both about financing the NCS, and how that financing is framed. Social care is an essential and fundamental public good, and the adult social care sector alone provides employment for almost 135,000 people, mostly womenⁱⁱⁱ. When we invest in social care, we enable people to live their lives with dignity and participate equally in society, whilst valuing the skills of the workforce and bridging the gender pay gap. 

I use the word “invest” very deliberately, as that is how we must see funding for social care. It is a positive investment in society with significant beneficial returns, not a negative “cost” or burden that must be borne^iv. The Scottish Government must prioritise the investment necessary to transform social care, including via fair pay for the workforce and delivering on its commitment to end non-residential care charging. The principles of human rights budgeting should be embedded in all budgets, both national and local, establishing clear principles as to how to direct that investment and, crucially, measuring the impacts and providing direct lines of accountability. 

For the ALLIANCE, improving the delivery of social care in Scotland is long overdue, and that improvement matters far more than what structures we entrust with doing so. The National Care Service is the route the Scottish Government have chosen to go down and we believe there is the potential for it to deliver the change necessary. But as the legislative process moves slowly forward, we cannot allow the laudable ambitions of co-design and a human rights based approach to be lost to political expediency and fear of sharing power with the people who the service should work for. 

End of page.