Delivering Feeley (Part 1) – Ron Culley, Quarriers

Ron Culley of Quarriers in dark suit and tie, side on.

Ron Culley

In this two-part opinion piece, Dr Ron Culley shares his thoughts on the Feeley Review, the National Care Service and the opportunity we have within our reach to be ambitious, values focussed, and ensure people are at the heart of change.

In part 1, Ron raises important questions about governance, employment and accountability within the proposed new set up, which includes the National Care Service framework.

Ron will share these and other ideas during his discussion with journalist Pennie Taylor on 29/6/21 as part of the GCVS ‘Our World Reimagined – Social Care’ series.

Delivering Feeley – Part 1

Scotland stands on the cusp of creating a National Care Service. We arrive at this moment having witnessed the development of a series of contradictions across twenty years of public policy.

We are a nation capable of delivering brilliant and imaginative support for people; and yet most agree the system that oversees it is beset with challenges. We have delivered ground-breaking legislative reforms like the Social Care (Self Directed Support) Act (2013) and the Carers Act (2016); but have struggled to see their potential realised. We have invested hundreds of millions of pounds in policies like Free Personal Care; and yet the social care sector is thirsty for much-needed investment. We have committed as a nation to deliver the living wage for care workers; and yet care remains a low pay sector. We have witnessed demographic change and increasing levels of need; and yet there are fewer people supported in the social care system today than twenty years ago.

How do we make sense of these contradictions?

Well, Derek Feeley, the author of the recently published Independent Review of Adult Social Care in Scotland, has a good go at it.  The report is rich in ideas and strong on values, meaning it is well positioned to deliver the reforms needed to improve access to care and to fix the clunky bits of health and social care integration.

It also puts a lie to the idea that ambitious policy reviews require a great deal of time to be fully and comprehensively expressed – this work was delivered in a matter of months. Reading through the report, it’s certainly well-argued.  Which is not to say everyone is a winner: councils in particular stand to lose the statutory responsibility for the assessment of need and the procurement of care.

Around a quarter of the local authority budget could soon enough be handed directly to the Integration Joint Boards from the Scottish Government.  There is a fear within local government that the proposed reforms erode local democracy in Scotland and weaken the institutional power of local authorities within an overly centralised state.  Having spent time in the local government community, I continue to see an important role for local accountability within a national service – and I remain a great supporter of local authorities’ crucial role in our civic life.

There is no doubt, however, Feeley’s recommendations would simplify the complex governance that oversees Integration Joint Boards (IJB). By removing Chief Officers’ required deference to Health Board and Council Chief Executives, the need to pre-negotiate commissioning proposals is removed.  And by formalising the voting rights of those IJB members who were previously disenfranchised – unpaid carer representatives, people who need social care and third sector representatives – we may see bolder changes to local health and care systems follow.

The report is also very clear that this move will not nationalise the delivery of care, in contrast to the NHS, where healthcare is delivered through a single public sector institution. If anything, the report highlights the added value and quality of third sector providers of care.  In respect of the private sector, a pragmatic position is reached.  Whatever you think about the profit motive, it is impractical to imagine government buying out all private sector interests – it is an unaffordable proposition. And yet, it is a debate that refuses to go away, with politicians pre- and post-election expressing doubt about the longer-term role of profit in social care.  Progressive voices within the private sector argue that ‘commissioning for the public good’ is the way forward, which will focus, rather than remove, the profit motive.

In broad terms, the report proposes that the social care system adopts the same governance arrangements that oversees healthcare: a national service directly accountable to Scottish Ministers, with delivery through local boards whose job it is to commission or provide services.  The one new element will be the creation of a national board – an all-seeing representative body to ensure consistency of standards and universality of rights.

Within this context, there are a bunch of practical governance questions that will need to be resolved.

If IJBs are to become emploOur World Reimagined Series Logo in black and purple textyers, who will work for them?  Everyone imagines the Chief Officer and those involved in strategic commissioning, with a Chief Finance Officer to keep the money in check.  But I can’t see how we can deliver effective strategic commissioning if it is divorced from micro-commissioning, which in essence is the care management function performed by social workers.  And if you set out on that road, a series of further questions very quickly open up.  Do we want to separate out children & families, criminal justice and adult social work functions? Better to keep them together, surely?   After all, real lives are complicated and perverse outcomes can be driven into systems by arbitrary professional boundaries.

If you migrate the entire social work community into IJBs, what about community healthcare workers?  The GP contract is already slated for IJBs to oversee.  It would therefore make sense to include community nurses, AHPs, and community mental health professionals and maintain the operational function of Health and Social Care Partnerships. To do otherwise risks the progress we’ve made with integration.   But does that mean healthcare workers will lose the NHS as their employer?  And what about hard fought for terms and conditions?  Will there be an equal pay risk for the IJB as an employer?  And, if IJBs take charge of primary and community healthcare, does that pave the way to reform Health Boards, leaving them with responsibility for the provision of secondary and specialist care?

There is much to consider here.  In part 2, I consider how we take on board these questions and how we make Feeley happen.

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