Care is to be centralised again - and it’s still a bad idea

The days since the announcement of the Programme for Government have witnessed rising concerns about the centralisation agenda which is being proposed. The general perception seems to be shifting from seeing this as 'just more bureaucratic reorganisation' to a genuine threat to the governance of public services in Scotland.

And there is on area where this concern is greater than most – in care services. Today the Health and Social Care Alliance is warning that subsuming care services into a side function of the NHS will put care service at risk.

At Common Weal we're minded to go further in our concern. We see this as fundamentally poor quality policy making that genuinely risks care services, because it stems from a fundamental misunderstanding of care – and a refusal to listen.

The Scottish Government's starting point is fair enough; Common Weal has argued for quite a while now that there are problems with the governance of public services in Scotland. Those problems were of centralisation, undue control exerted by the management classes, concerning levels of commercial conflicts of interest, lack of accountability and lack of transparency.

The problem is that the Scottish Government's response seems to be to make each of these worse. There will be two much larger, much more centralised health boards which are inevitably going to be closer to government and therefore likely to be under greater governmental direction.

It will be harder to get granular information out of much larger organisations and it is almost impossible to see how this can make the health service more responsive to local needs and issues. In fact the further we get from the Programme for Government announcement, the more concerning this seems.

But this is particularly threatening for social care – for a number of reasons. For a start, the main reason the Scottish Government's National Care Service proposals fell apart is because the government was insisting on complete centralisation and the care experts pushed back, making clear that care is not a centralised service.

Care is generally a very local issue indeed. It involves finding people housing, helping them to adapt their existing houses, organising home care in their house, offering paths through addiction services or arranging residential care close to family. These are all activities that require local knowledge and links to services provided by central government.

Also care is most certainly not just a side function of health. In fact they are completely different disciplines. They are closely linked – but in exactly the same way that food systems and the NHS are closely linked. That does not mean that we have merged Food and Drink Scotland into the NHS board structure. They do different things.

Care and health are complimentary, not subsidiary. Centralising and deprioritising care is a major mistake, one the Scottish Government appeared to attempt in the last administration, one they came to regret and walked away from.

So why is this happening? This appears to be a particular pet project of the First Minister. He has a strange obsession with 'delayed discharge', or so-called 'bed blocking'. This is the single issue in the NHS that he keeps returning to. He appears to see the NHS like a spreadsheet with one snarl up that if he could fix it, the rest would sort itself.

This is not a realistic assessment of the health service. It is also the case that throughout his career our current First Minister has always had the instincts to centralise and gather more control and power directly to himself. This also appears to come from a 'spreadsheet mindset' which thinks the problem is the lack of ability of policymakers to micromanage problems.

And the result of this is that this administration appears to see care as a 'commissioning service', the purpose of which is to 'buy beds' from often patchy-quality private care homes so beds can be unblocked and the NHS can be saved. This increasingly became the apparent driving ambition for the National Care Service model, a model which failed. It demonstrates a concerning lack of understanding of what care actually is.

The worry here is that it doesn't look like the Scottish Government is taking no for an answer. Not only does this appear to be a rerun of the centralised, top-down care service model that failed last time, it appears it could be an even more intensive version of it.

Common Weal still has a detailed vision for what modern care in Scotland should look like. At the moment the Scottish Government is drifting further from the spirit and intention of this work by the day.