The Great ‘Doughnut Fallacy’ of social care in Scotland 

Minister for Social Care Marie Todd last week announced changes to the proposed National Care Service (NCS) Bill. The most significant of which is the removal of Part 1 of the bill, which focused on the structural reform of integrated social care and community health. This means the bill will now proceed with only Parts 2 and 3. I can’t help but note the passing of the ‘Welfare of Dogs’ Act in the same week and reflect upon what that means for how we value our citizens. What is crucial now is that we do not wait for the Bill to reform social care. A briefing was sent to all Scottish Care members with more detail, but here’s what we know: 

First, it’s important to acknowledge that the plan for a complete overhaul of the social care system, through the structural reforms in Part 1 of the National Care Service (NCS) Bill, has been dropped. This is where the system arguing with itself about who should run things got in the way of making a difference for people. It’s the great doughnut fallacy of social care. 

During the pandemic we experienced a health takeover of social care. They brought with them outdated ideals of person-centred social care. Whilst this was a positive initiative of its time, over 2 decades ago social care switched to person-led care and support. Person-centred was a way of reinforcing the need of the system to connect with itself with the individual citizen at the centre. However all too often what would happen is that the individual in the centre would find themselves in a vacuum surrounded by a system determining their needs, often to the detriment of the individual. This regression to person-centred caused a culture change which ripped a hole in the heart of the independent review of adult social care and delayed the implementation of meaningful change.  

With the structural reform proving too difficult, I am however reassured by the clear language shift to person-led in the Ministers speech reinforcing the need to remember why we are doing this. Put simply, for people not power. 

So what remains in the bill? 

• It includes “Anne’s Law”, which appears to strengthen visiting rights in care homes although in practice the role of Public Health still has a power to overrule any decisions, making this legislation have no greater impact that what already exists. 

• It aims to improve information sharing between health and social care services. Many of you will know data is one of the pedestals I like to climb upon, but that is because it is a real area of opportunity. Especially with the adoption of ethical AI. However, it will only work if it meets a vision to reduce bureaucracy and improve the user experience. I wrote about this with Dr Tara French some years ago now in Seeing the Diamond in Social Care Data, but the principles remain the same. Alongside this, there is a need to embrace digital to augment the care experience, offering people more autonomy and freeing up care workers to get back to delivering care. 

• There’s also a plan to establish a national care service advisory board. This is meant to be an independent body, including people with lived experience, that will help to improve the quality of care across the country. It will provide advice on national programs to support improvements and will monitor and report on local frameworks. However, it’s not statutory, so it may not be as powerful as it could be. What is important here is how the board can ensure transparency and influence over poor practice in all parts of the system. This will be supported by work on  

• Ethical commissioning and procurement which remains in the bill. This is where real change towards person-led sustainable and quality care can be made, but only if it is enforceable. Financial constraints and the persistent underfunding of social care and support for a decade has led to a time and task takeover meaning that providers are not commissioned to deliver the care and support that people really need to live well. In addition, delays in payments to care providers are putting them at further risk of collapse because they cannot meet cash flow demands. Providers are closing. Staff are exhausted and undermined. There is additional pressure on families, and worst of all, people are being failed. In response to the statement that Scottish Government has increased funding for social care by 25%, two years earlier than planned. I wonder how much of this has been used to meet public sector pay increases or simply to meet inflationary rises. Funding remains a concern and transparency, and good governance is still needed for system change to embed. 

So there we have a list of what should perhaps be the items for the agenda of the first National Care Service Advisory Board. Whatever happens next, it is critical that changes are person-led and focus on the needs of individuals, ensure care workers are properly supported, care providers experience full economic cost recovery, and that the system is accountable, flexible and efficient. Without these critical foundations, the changes to the NCS bill will not deliver the required improvements of the Independent Review of Adult Social Care and the doughnut fallacy will remain strong. However, if we collaborate with intent, we can have our cake and eat it. 

Karen Hedge
Deputy CEO, Scottish Care

Human Rights Day is celebrated globally on December the 10th, the day serves as a powerful reminder to protect fundamental rights for all. In Scotland, organisations like Scottish Care use the occasion to highlight challenges and progress in social care. Scotland also observes this day with organisations, activists, and communities hosting events, discussions, and campaigns to raise awareness about ongoing human rights challenges and celebrating advancements in this field. 

At Scottish Care, we utilise this day to celebrate the amazing work from our members and colleagues championing human rights in their communities. One standout example is the Silver Pride Project, where our colleagues in Ayrshire are contributing to creating safe and inclusive spaces for older LGBT adults living with dementia. It showcases how celebrating the right to freedom of expression can translate into practical change for marginalised communities. 

Scottish Care also celebrates the work of our colleagues in Ethical Commissioning, which emphasises integrating human rights into social care contracting. In 2023, workshops highlighted how current social care procurement models can infringe on the rights of those who access care and support. Recommendations from the subsequent report included making rights-based care a contractual prerequisite and ensuring shared accountability between providers and commissioning bodies. This approach aims to enhance the dignity, independence, and outcomes for those accessing care. 

However, despite these examples, systemic issues persist. For one the Scottish Government’s 2024 Budget. This budget allocated £21 billion to health and social care but failed to provide ring-fenced funding for social care services. Scottish Care’s response to the budget highlighted that this omission places providers under immense financial strain, exacerbated by unaddressed National Insurance increases. We are working actively to address our concern with the Scottish Government.  

Another issue that persists is the pushback of the Human Rights Bill. This Bill was supposed to create a legal framework for the Scottish Government to embed international human rights within domestic law and drive transformative, positive change for people. We responded to the call for consultation of the Bill, though we had concerns we supported the ambitions of the Bill. However earlier this year the Bill was taken out of the 2024-2025 programme for government, with no clear plan of a way forward. 

As part of the Scottish Food Coalition, we are advocating for the reintroduction of the Scottish Human Rights Bill into the Scottish Government’s agenda for this term, through the #BringBackTheBill campaign. The delay in the Bill’s progress has sparked widespread concern amidst worsening economic conditions. This event will unite organisations, grassroots groups, and individuals under the banner #OurRightsOurFuture, urging the government to prioritise human rights protections.  

Demonstration details:  

• Date: Tuesday, 10 December 2024 

• Time: 10:00 – 14:00 GMT 

• Location: Scottish Parliament Building, Edinburgh 

•  More information is available via Eventbrite