Localism vs National models of care: a false dichotomy?

This week Scottish Care has published our Care Manifesto for the Scottish Parliamentary Elections. It has been developed by my colleagues to suggest the areas where they believe the most significant changes in social care need to happen. One of these relates to the proposed development of a National Care Service as suggested by the Independent Review of Adult Social Care, also known as the Feeley Report. I have mentioned in a previous blog how I personally consider the concept of developing a ‘social covenant’ to be one worthy of further exploration and development.

What is meant by a National Care Service is something which has received much consideration since the publication of the Feeley Report. The Scottish Care Manifesto has stated that:

‘We believe such a service can drive consistent, high quality social care support if its’ role and remit is clear and it is developed in partnership with people who have a right to receive that support, the social care workforce and providers. We are presented with an opportunity to improve relationships and understanding, and to rightly elevate social care to equal status with NHS Scotland in terms of leadership and accountability.’

I could not agree more – the potential is enormous. But so too sadly are the obstacles to achieving such an outcome. One is the resistance to the very concept of a national service because of what has been argued as a risk of centralisation and a threat to what is presented as the benefits of keeping things ‘local’. I want to give consideration to some of these arguments in this short blog and to suggest that this is an erroneous and false dichotomy and that the arguments often presented have more to do with self-interest than a coherent defence.

The Feeley Report heard from hundreds of voices, especially those with lived experience of using, working and delivering social care supports. What they heard was a shameful litany of disappointment that original, human rights-based legislation, such as the Carers Act and Self-directed Support Act, had singularly failed to be properly implemented. Scotland has, as I have often argued, enough progressive social care legislation and policy to make this one of the most forward-thinking countries in the world. But we are not. There are many reasons for this, and the Feeley Report articulates the ‘implementation gap’ as a major reason for the disrepair and malaise that is afflicting social care not just now but for decades.

These voices and the testimony of missed opportunity and failed implementation cannot be ignored or set aside as insignificant or unimportant. It is also clear that the fractures and failings of the system of care cannot be dismissed as simply the results of fiscal austerity. The failures to implement progressive social care, to deliver models of collaborative partnership, which give citizens control and autonomy over their care are decades old. These failures are systemic and as Feeley underlines, include the contradictions of diverse charging policies and the postcode lottery of provision dependent upon where you are in Scotland, which local authority department you happen to be under and what focus happens to exist in a particular local area. In other words, and though it was not put as bluntly as this in the Report’s analysis, the failures are in large part because of the very nature of localism which has created such inappropriate divergence from policy alongside piecemeal and patchy implementation. It has been argued that diversity of approach and flexibility of local implementation was so critical. It was not. In an attempt to avoid ‘top down direction’ the world of social care has received local led atrophy.

The delivery of social care placed in the hands of local authorities has clearly failed for thirty plus years and those who use supports and services deserve much better than what they have received. Again to underline lest I be misunderstood, this is a critique of a system not of the individuals at local level charged with working within it. Having trained hundreds of frontline social workers in the SDS Act I never met one who wanted to limit the control, choice and autonomy of someone who used social care support, but I have met plenty who railed against the system, the controls, the oversights and constraints which at local authority level prevented them from truly and authentically doing the job they loved – to help change people’s lives for the better.

So it is perhaps not that surprising that the voice of local authority government has been resistant to the concept of a National Care Service.  In true ‘turkeys voting for Christmas’ style they have argued against the loss of ‘local democracy’  and ‘accountability’ whilst ignoring the Report’s damning critique of failures over which they have presided for decades.

We get a flavour of some of this critique from local government in the COSLA statement on the Feeley Report which whilst welcoming the emphasis on those who use supports and its workforce, goes on to state that Leaders ‘unanimously expressed their grave concern at the recommendations around the future governance and accountability arrangements contained within the Report.’ It went on to say:

 ‘Council Leaders together voiced their opposition to the recommendation which proposes the removal of local democratic accountability from Adult Social Care and the centralising of the service under a National Care Service with accountability falling to Ministers, a move that they described as being detrimental to the local delivery of social care and its integration with other key community services.  They also felt that given the level of funding set out in the Review, Local Government would be well placed to continue to deliver this vital service.’

This presentation of social care reality simply does not ring true for the vast majority of those who have received social care and who spoke to the Feeley Review group nor to those who have as charities, not for profit and private providers delivered social care under local authority commissioning approaches which have consistently treated in-house provision more favourably than out-sourced contractors.

A further joint statement was made with the Scottish Government days before the Parliamentary election commenced. That statement re-stated COSLA’s concerns that ‘it is evident that there is significant discussion needed around the areas in the review that relate to governance and accountability within the report.’ The Cabinet Secretary observed that:

‘Radical reform is never easy and I understand COSLA’s concerns around governance and accountability and we will continue to discuss those. There is much on which the Scottish Government and COSLA agree and by working closely together on the fundamental principals in the report we will overcome the obstacles to build a world leading care service.’

I hardly need to add that those who use social care support, the organisations. which provide the majority of it, and the workforce also need to be at the table lest it become a classic cabal of inter-governmental decision-making.

Resistance to radical change from vested interest is nothing new. When the NHS was being created in the late 1940s we saw the same. GPs and local committees voted 10 to 1 against the proposals of a national service in 1946, demanding things be kept local, ‘near the people and locally led.’ The politicians were also disunited with the Winston Churchill led Conservatives voting against the proposals no less than 21 times. But the vision of a national service prevailed over what one commentator described as ‘obsessive localism.’

What all of this highlights is the age-old debate between national and local approaches. It has aye been thus and those of us old enough to remember debates about a national police service  – which we achieved – or a national education body – which we did not get – will recollect the reaction of local government elected leaders at the perceived loss of influence, budget and accountability. But in reality is this not just a false dichotomy? For social care it is not a choice between a local model on the one hand and a national one on the other. It is a choice between a model accountable to Government centrally with a strong local voice and enabling of local choice or one which is dressed up in the clothes of localism but is as remote and detached from the citizen as any distant central service. risks being. What social care as a whole needs in Scotland at this time  is a change to the failures of the present.

If you look across Europe the balance between local autonomy and central control is a perennial issue in the territorial organisation of states. How much power do you hold in the centre and what do you devolve or delegate to local level? Equally there is much debate today about how you re-invigorate local democracy as right across Europe people have become more and more disengaged from local decision making unless its relevance is seen as being of direct interest and impact. At the same time there has been a renewal of democratic engagement in national and regional governments.

Time does not permit in this blog to consider further the local and national dichotomy in its widest sense but from the perspective of social care,  being able to make decisions locally which directly impact on your care and support is clearly beneficial. I am not arguing, and I do not think anyone seriously is, that all decisions, policies, interventions and accountabilities should always and inescapably be at a national level. But in the timeless tug-of-war between centralisation and decentralisation what should remain the priority is how do we enable the person who uses the support or service to feel in control, autonomous and in the lead? The person and not the system is what matters.

In an age where it is possible to exercise influence and autonomy through the pressing of a phone key, where apps have enabled real participation and meaningful engagement; where democracy has the potential to be ever more proximate and personal, then it is perfectly possible to reform the accountabilities of social care without maintaining a failed status quo.

There are many lessons which need to be learnt from the experience of the pandemic. One of these has undoubtedly been that when it mattered most in a crisis there was an ability to lead from the centre, to instigate change and initiate intervention but whilst still taking account of the uniqueness of the particular and the requirements of the local. We did not have 31 different pandemic responses but one response delivered at local level – albeit as social care providers can attest the multiplicity of local approaches was itself beset with difficulty. There was clearly a time and a benefit for a centralised model and if it works in a crisis it can work anytime.

There will be much debate in the coming weeks and after the Parliament is selected no doubt in the coming months, I hope we can all agree that the local-national accountability and delivery issue does not need to be an either/or.

The Feeley Report envisaged a transformed local accountability in Integrated Joint Boards where representation was real, local, participative and immediate. Most importantly the Report and its ideal of a national care service held before us a vision that those who matter most, the folks who use and will use social care supports in the future, were really in control and in charge, were the engineers of decision-making – that is a vision we simply cannot lose, and which will outlive all the transitory interests of the system defenders. It is their voice, not those of local or national politicians, of workers and the unions, of providers and their representatives, that must be at the heart of all design and delivery. We cannot fail to build a future service rooted in that voice.

Donald Macaskill

Last Updated on 23rd April 2021 by Shanice