There is much discussion at the moment about the proposals for a National Care Service (NCS). The plan is for it to be envisioned on very similar lines to the NHS.
The former Labour leader, Jeremy Corbyn, promised a National Care Service in the 2019 manifesto but his successor, Kier Starmer, has said he will be writing the manifesto from scratch. The independent left-leaning think tank, The Fabian Society, announced in July that it’s developing a roadmap towards a National Care Service for England. A study will make recommendations to the Labour party policy review and to shadow Health and Social Care Secretary, Wes Streeting MP. The research is funded by Unison and is led by The Fabian Society’s General Secretary, Andrew Harrop.
Wes Streeting has been vocal in his support for the new care service and said, ‘I would love to see a National Care Service delivered exactly on the same terms as the NHS, publicly owned, publicly funded, free at the point of use.’
Publicly owned, publicly funded and free at the point of use. All sounds very attractive – or does it? Won’t we just be in danger of swapping one top-down failed system – local authority commissioning – with another equally unresponsive state bureaucracy?
Models of care
The NHS model works for health; it’s not perfect but nothing ever is. Free at the point of delivery is efficient and the model has stood the test of time. It is largely cherished as a national treasure. Granted it may be underfunded but the fundamental architecture fits and is popular; it feels fair.
Is social care the same as health? Or does it need a different architecture? Or indeed does it need any architecture at all? The NHS is fundamentally a science-led, evidence-based medical model of treating illness and disease. It’s like the nation’s mechanic. I take my car to the garage to be fixed and serviced – just like I take my body to the doctor if something is misfiring. The medics diagnose and tell me what they think the best fix will be, based on science and experience.
Generally speaking, if my ignition coil is shot, then I need a new ignition coil. If my arm is broken, I need it resetting and splinting. There may be a narrow set of treatment options but, fundamentally, there is not much scope for exercising my consumer choice and, arguably, neither should there be. It wouldn’t make much sense to be offered an amputation or to hear a medical professional say, ‘let’s see if it gets better on its own’!
That’s not how social care works. The same want or need can require very different solutions depending on a person’s individual situation, attitude to risk, relationships, life experience and neighbourhood. The social care sector should be as diverse in its offerings as the people it serves. We’ve endured too long with a well-meaning but fundamentally unresponsive architecture. Commissioner sovereignty has leant towards meeting the needs of commissioners and not the people drawing on social care – protecting budgets, narrowing choices and limiting progress. The models of care, design of services and customer choices have changed substantially little since my first shift as a care assistant in 1984.
Before we rush into a ‘silver bullet’ of an NCS, shouldn’t we first decide what we want social care to look, feel and taste like? Can we envision a future as proposed by Social Care Future: ‘Don’t we all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us?’
The crucial part of this is the ‘we’. What is good, what is wanted and what is demanded is defined by us, the people drawing on social care. What is decided by the person; us not them. This is the difference and this is the concern of an NCS – that it will decide, will limit choice and will continue to embed sclerosis. How will the aspiration of a ‘publicly owned, publicly funded, free at the point of use’ drive change?
Publicly owned. Why? There is not much evidence that publicly run necessarily has the intended effect on quality or efficiency. There have been just as many scandals and failures in the health service and publicly run social care. Isn’t it the attitude and ethos of those running services which can be lacking or wanting in public and private sector organisations? Shouldn’t we be ensuring that the fundamental engineering of the sector is fit for purpose, thereby maximising the chances of getting it right? What does publicly owned add to the quality, diversity and effectiveness of social care?
Publicly funded, free at the point of delivery: if it is free at the point of delivery, does that mean that my consumer sovereignty is stymied? Does this mean I need permission? Publicly funded, if realised in the same way as local authority commissioning, risks further disempowering of the consumer and inevitably leads to rationing and limited choices.
Surely what we want to encourage is a varied and diverse social care offering, where those who draw on social care are the key agents in the design and delivery of the services they draw on. A single national health and social care workforce. Recruited and inducted, trained and developed, together, across the NHS and social care. A single pay spine. Shared values, the same competencies and skills. This would elevate the status and esteem of social care and improve the mutual understanding and ability to work together across health and social care. It would also provide the public with confidence.
Of course, we are just about to create another addition to team quango in health and social care with the creation of the new Integrated Care Systems (ICS). Allegedly given the money and the power to bring the systems together in a coherent and effective way. Metaphorically to ‘knock heads together’. Where would a National Care Service fit into this already crowded superannuated room?
Instead of trying to ‘commission’ or ‘direct’ the system, why not instead put in place the engineering that allows this vision? Build into the system some key framework and levers – engineering, which allows the consumer to buy with confidence from organisations with the right values and a workforce that is skilled, competent and valued. Simplify the architecture and beef up the engineering.
Market regulation
For decades, we have quibbled over the true cost of care, with a multitude of reports from charities and consultants. If we standardise the workforce costs with a national workforce pay scale, then it’s not rocket science. It would be fairly easy to establish a minimum fee for care homes and a fair rate for homecare workers: to establish a ‘true rate for care’.
In many sectors, there is a market regulator – OfGem, OfWat, etc – which balances the Value for Money (VFM) for the consumer against the needs of organisations to achieve viability and invest in the future. Why not for the care sector? To ensure that, in return for a ‘fair price’, there is investment in quality and that excess profit is not taken. This could take the form of a market regulator, who is able to scrutinise providers and call out those sending ‘rent and consultancy fees’ to the Cayman Islands. We need market oversight that regulates fees and ensures charges and profits for care are within reasonable and defensible grounds. OfCare, anyone?
Consumer power
Sovereignty in the market needs to shift significantly into the hands of those who draw on services. Providers will then deal directly with customers and innovation and significant market segmentation will follow. All markets change if people demand more of one thing or indeed stop buying another. This mechanism for change is missing. The consumer, as in many markets, needs support in navigating but this needs to be a fundamental change from ‘assessment’ to ‘facilitation’ – it’s a power shift.
How we pay for it and who pays is a whole different question. But surely before we decide the how – publicly owned, publicly funded and free at the point of delivery – we should first decide what we want it to be? Then, we should look at the policy that will help to achieve that. We seem to be putting the cart before the horse.
We need a new system with solid engineering and little architecture. We need to look at the engineering of social care – what needs to be in place to widen choice, drive innovation and, crucially, empower and protect consumers. Let’s embrace a much more flexible, vibrant and fleet-of-foot social care sector. Yes, embed the fundamental engineering, workforce and market oversight but let the consumer drive the market, not the system. Otherwise, in the famous words of Henry Ford, ‘You can have any colour you want, as long as it’s black.’
John Kennedy is an Independent Consultant and Commentator in adult social care.
Email: [email protected] Twitter: @JohnnyCosmos
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