From Cradle to Grave: Will the new National Care Service support people of all ages?

‘‘The outcomes for people like me have been dire, regardless of whether it’s been times of boom or bust or whichever political party has been at the helm,” says Thomas Carlton, a social worker who spent time in care as a child.

Carlton is now charged with helping implement The Promise, a pledge that flowed from a report of the same name which was published in 2020 and seeks to overhaul an outdated and disjointed care system to help transform the lives of children and young people.

Carlton says it’s down to a combination of “luck and opportunity” that he ended up where he is, while one of his brothers is in prison. He has a mantra he likes to repeat about “hoping for tomorrow, not seeking blame for yesterday”.

But while hopes were high at the outset of The Promise, delivery has been patchy. Responding to publication of the report in 2020, First Minister Nicola Sturgeon said reading it had made her feel “very emotional”.

“The world described in today’s report – of a care system that feels fractured, bureaucratic, unfeeling, stigmatising, and mired in impersonal language like placements, contact and respite to describe what should be loving relationships – is one that I have had recounted to me many times,” the First Minister said in a statement to parliament. “That must change.”

Yet speaking to STV earlier this month, The Promise’s head of oversight said the lives of many care-experienced children in Scotland had failed to improve over the past two years and may even have got worse. 

Those who work for the organisation say this failure is not due to a lack of money or political will, but rather the impact of the pandemic, which has further isolated the vulnerable, further endangered the at-risk. 

Indeed, if Covid can have one positive legacy, then perhaps it can be the transformation of a ‘care system’ which the virus showed to be horribly broken and out of date. Just as the NHS was created out of the horrors of the Second World War, it is hoped that with the darkest days of the pandemic receding from view, a new social care system can be built which puts equity and compassion at its heart. 

A key component of that will be the new National Care Service, variously described as the “biggest public sector reform for decades” by the Scottish Government and as a “power grab” by its critics. While funding for social care is being increased by £800m over the course of this parliament, that is likely to be a fraction of what the service will ultimately cost. 

According to the Scottish Government, there were around 245,000 (1 in 20) people in Scotland, of all ages, receiving social care and support before the pandemic. While the new National Care Service will put adult social care at its centre, it could be scaled up to take on services currently provided by local authorities, such as children and young people; community justice; alcohol and drug treatment; and social work.

Derek Feeley, a former chief executive of NHS Scotland, led an independent review of adult social care, which was published in February last year. A video made to accompany the report shows the scale of the challenge. It features a care home resident, a dementia sufferer, a young man who has battled addiction and Marion, a mum who has had to fight to access care for her disabled daughter Laura.

“We asked for a life where [Laura] could have some choice or reach her potential,” she says in the film. “Whatever we were asking for wasn’t fancy nancy – it really was basic human rights.”

Feeley says the creation of the new National Care Service is the biggest public sector innovation in Scotland since the advent of the NHS more than 70 years ago. But he says it must be accompanied by a series of other changes about the importance we attach to care and the way we treat not only social care staff, but unpaid carers.

“The creation of a National Care Service is not some sort of magic bullet that’s going to solve all our problems,” he says. “We still need to change the narrative around social care, seeing it as an investment, not a burden. 

“The concerns people expressed to us [during the review] were pretty consistent… it was that you couldn’t really get access to social care support unless you had some sort of crisis in your life and it was about how challenging the assessment processes were. People felt as if they had to fight for everything they got and everybody, whether it was people using the services or those working within them, felt undervalued.

“I think you could reasonably describe those concerns as systemic and they’ve also been reasonably longstanding. Covid impacted on some of it, but most of those features pre-dated the pandemic.”

Of course, finding a solution to the social care crisis is not just a Scottish problem. Boris Johnson won the 2019 general election while promising to “fix social care once and for all”. In England, much of the debate has centred around how the system will be funded rather than what it will actually look like.

Last month, among opposition from some of their own MPs, both Johnson and Chancellor Rishi Sunak confirmed plans to press ahead with a National Insurance rise which will be collected as a new Health and Social Care Levy. The tax increase is controversial as critics believe it unfairly burdens those of working age who are already struggling with a cost of living crisis. 

While the Scottish Government has yet to lay out in detail how its social care reforms will be paid for, the UK-wide increase in National Insurance payments will provide additional funds for devolved health budgets. Further information on the funding settlement is expected when the legislation is published, but economists at the Fraser of Allander Institute have indicated that a large amount of additional funding is likely to be needed, warning that an “underfunded National Care Service is unlikely to do any better than the system it seeks to replace”.

Feeley, who previously help lead the US not-for-profit Institute for Healthcare Improvement (IHI) says that unlike the debate in England, talk of reforming social care in Scotland has not become bogged down in the finances.

“We’re having a mature debate in Scotland about what social care should be and how it should be made available, about how we can change the ethos of it from [being] market-driven as it is south of the border, to a much more collaborative approach,” he says.

But what about the role of the private sector? Currently, many of these services are provided by private companies, with much of the debate around care for the elderly centring on the often exorbitant fees charged by private nursing homes. 

“I’ve never thought the best investment for public money was in buying out the private sector,” says Feeley. “I would much rather put money in the pockets of social care staff or in the budgets of people who receive self-directed support. That’s where we are. 

“Public, private and third-sector organisations need to be, as far as possible, on a level playing field. We need to bring quality, ethical considerations and fair work into the commissioning process and all of that needs to be done in a much more transparent way so that we can see where the money is flowing and who’s on the receiving end of it…”

Just as the politicians hope to emulate the post-war ambition which led to the creation of the NHS, so too has some of the rhetoric of that era been borrowed, with calls for “cradle to grave” care, a phrase immortalised by Winston Churchill.

While Feeley’s report looked only at adult social care, he heard repeatedly of the challenges many face when moving from being in care as a child to attempting to access adult services.
Kenny Murray, a campaigner who spent time living in care as a child, says that despite now being 31, he continues to live with the impact of childhood neglect.

“I’m doing okay just now, financially, mentally and health-wise, but that’s because I’m in a good position in life. But I’m paying a dentist thousands of pounds to fix my teeth which was the impact of missed appointments when I was in care. That’s something I can pay for over time, but there will be people who won’t be able to…”

He says we need to remain vigilant about the potential for the introduction of the National Care Service to undo or undermine the work done by council-led children’s services.

“But ultimately, from my experience there’s a need for lifelong support for care-experienced people because the impact of care is very clear, whether you speak to someone who’s in care now or someone who was in care 40 years ago. All the evidence points to a lifelong impact, so the less changing of hands in terms of services, the better.”

Government ministers don’t have too far to look to find evidence of how innovation in care can go badly wrong. The angry backlash caused by the ill-thought-out Named Person scheme provided a salutary lesson in that regard. 

Indeed, the cynically minded might point to The Promise’s apparent lack of progress and say it’s nothing more than a PR exercise.

Brian Houston, head of support at The Promise, says he understands the cynicism, but insists progress is being made. He wants to see a system created which looks after people throughout their lives and becomes less fixated on age.

“We need to recognise that if there are situations where the state has to intervene, and by intervening in a child or young person’s life they interrupt the normal connections they might have with family and community, then you need to be in it for the long journey – right through to the end,” he says.

“We’ve tended to focus on parenting as something which ends at 18 or 25 when in fact in our own lives, parenting continues. We need to create a system where people are helped through their whole life journey.”

Carlton, his colleague, says the cynicism extends to care-experienced people themselves, who have often been promised much with little being delivered. He says he remains pragmatic and is not living with what he calls a “Disney-esque hopefulness”.

“If The Promise is not kept, those who had to endure the unimaginable during their childhood will have to continue to endure that,” he says. “That’s not something we should be willing to contemplate.”