Jonathon Shafi

Jonathon Shafi

The Private Sector Capture of the ‘National Care Service’

Reading Time: 9 minutes

Jonathon Shafi speaks to Nick Kempe a leading expert on care, formerly Head of Service for Older People and Adults in Glasgow chair of Common Weal’s Care Reform Group, about the failure to establish a real National Care Service in Scotland.

This is an abridged version of an article from the Independence Captured newsletter.

Jonathon Shafi (JS): Nick, thank you for taking the time out to speak to Independence Captured. Your expertise on this topic will be of great interest to readers of the newsletter. To begin, what do you think are the essential problems with the care system?

Nick Kempe (NK): Okay, it goes back a long, long way. It goes back to Thatcher and the creation of a care market. But actually the central strand of that is partly to do with the fact that care wasn’t seen as being like other parts of the welfare state. In 1948, it was always left to one side and with local authorities. And then, because they never funded local authorities enough, Thatcher came up with the idea that the private sector would solve all of that. So one major strand is outsourcing and that has continued since the creation of the Scottish Parliament. I think that’s a very big driving issue.

I would say the second problem, linked with that, is what I would broadly describe as neoliberal attitudes. What we’ve seen happen in the care system is that while government has professed an interest in improving the quality of care, the solution to that has been to turn people who need caring into consumers. We’ve had a whole shift in discourse from need to “rights,” and here we are not talking about human rights, we are talking about consumer rights.

The other major element is that care has increasingly become seen as an adjunct to the health service to the extent that care has been collapsed into health. At its worst, and the Scottish Government has been particularly obsessed with this, has been the notion that if only we could integrate the two systems, we could solve the problems of the NHS.

What we’ve seen in the NHS is that the increasing population of elderly people means there is more demand, and we have as a result come to see more emphasis on what I would call “just in time” medical care. So when people are in a hospital for any length of time, bearing in mind older people take time to recover, as soon as treatment is finished, out they are meant to go.

The Scottish Government has spent 20 years trying to crack this issue, and it has led to this agenda of integrating care into health. On this they have absolutely failed, except for one moment. And that was during the Covid crisis, where they discharged lots of older people, still infected with the virus, out to care homes. The Scottish Government actually produced a report after that saying: “miraculous, this is the first time we’ve managed to solve the delayed discharge problem.” It’s incredible.

So I think those are a few central themes I would highlight.

JS: Sticking with the pandemic, how do you think it impacted the nature of the discussion around care?

NK: Well, I think Covid in terms of the impact on public consciousness, was absolutely transformative. People were exposed to all of these long-standing problems with the care system, and suddenly realised just how bad it was. I’ve already referred to the elderly discharge from hospital, but you could add other matters too, like the fact that care staff who were ill with Covid weren’t even getting sick pay or, for example, that many didn’t know how to use PPE.

Under media scrutiny, Covid exposed the deep rooted problems in the care system. And that, of course, is where the pressure for a National Care Service came from. Interestingly, it was actually a Labour idea, under Gordon Brown, who launched the initiative when he was Prime Minister. But it got nowhere. Then, Jeremy Corbyn’s Labour Party transformed the idea into a very different vision but that of course never came to be implemented

The idea wasn’t going anywhere in Scotland until the pandemic. But what’s happened since with the Scottish Government leaves a lot to be desired, partly because they really don’t want to look at what happened during the Covid crisis. In terms of the design of the National Care Service, despite being on the agenda because of Covid, it has taken absolutely no account of what went on during Covid at all.

When I was at the Health and Care Committee of the Scottish Parliament a couple of weeks ago, the convenor asked us to give some background on what we thought of the Bill. When I tried to say, well, of course, this all stems from Covid, I was then ruled out of order as that wasn’t answering her question. I think this illustrates, therefore, that there is a political block when it comes to looking at the lessons that could be learned from Covid

But perhaps the key point here is you could get a panel of experts together in a week, and you could produce a good report that would tell you everything that you needed to change about the care system as a result of Covid. I mean, it’s not difficult to do. We know the main things that went wrong.

JS: Interesting. Let’s come on then to discuss the development of the National Care Service in Scotland in a little more detail. Because when people read a headline that says the Scottish Government are going to deliver a National Care Service, they have a an idea in their head about what that means. But is there a gap between that phrase “National Care Service” and the actual proposal on the table?

NK: The thing about the term “National Care Service,” is that it transmits a very powerful idea. It’s something that can really inspire people. But in reality, if we ask whether or not the Scottish Government is producing something that can inspire people, the answer is absolutely no. And I think we see the evidence of that in the consultation to the National Care Service Bill. What’s interesting about that, is it’s not just the trade unions who have strongly objected because it hasn’t dealt with the labour force issues. That, one might expect.

But I’ve read all of the voluntary sector provider responses too, and almost all of them are extremely critical and doubtful about what the government is doing. What they’re saying is simple: this doesn’t deliver our vision. This is the voluntary sector who have in the past probably been the Scottish Government’s greatest allies. It would have been easy to predict that COSLA and others in the labour movement would be oppositional to the idea that the National Care Service should take power away from local authorities. Rightly so, in my view. But there are now a whole lot of people, some of whom you wouldn’t have predicted, who are against the government proposals.

Indeed, it’s very hard to see anyone who actually supports it. There are also some very, very critical voices in the disability rights movement. This is important because this includes people who need care for the whole of their lives and it is vital we get care right for them. There is a lot of doubt being voiced in those circles which were initially fairly supportive of the Government’s proposals and they’re now putting across some home truths, like actually what care needs is resources and without resources you’re never going to be able to come up with a credible system.

There is, in fact, quite a lot of unity developing around saying very frankly that the Scottish Government have completely failed to work out a strategy and an approach that can deliver care on the basis of need. SNP MSP Michele Thompson remarked recently that it was the worst piece of financial work behind a proposed Bill that she’d ever seen. Clearly this needs looking at again.

JS: This, unfortunately, doesn’t surprise me. But we do need to raise public awareness of the issues. There have been a number of statements made by unions raising concerns about the displacement of local government workers and issues around centralisation. Could you unpack this criticism a little more?

NK: Well, I think there are several concerns. Partly these are very traditional concerns about workforce, pay, conditions and so forth. Most of the social care workforce is chronically underpaid and have terrible terms and conditions. The one part of the sector that has actually managed to preserve a level of pay and conditions, and should be an example to everyone else, is in local government.

Now, what the Scottish Government is proposing is that the power to decide the resources allocated to care will go to “care boards” totally appointed by Scottish ministers. They will be then given a budget, and it’s quite predictable that that budget won’t be enough. So what’s going to happen is that care boards will look at their budget and see that they haven’t got enough money to meet demand.

What will then happen is that instead of continuing to commission services that are still provided by local authorities, there will be relentless pressure to outsource. That’s not going to take place in one big bang, but because of the impact of cuts and financial shortages and lack of resources, there will be an ongoing attrition of council services. This will take a number of years, but I think the unions are absolutely right to be concerned and to see this process as being a threat to their terms and conditions.

All of this is linked to another concern about the centralisation of care under ministerial control, with people being pushed to do more with less through inadequate budgets, resulting in more and more outsourcing. Local authorities have provided some checks and balances against that because where people object to what is happening they can raise issues with their local councillors and so on.

We’ve seen a very good example of that in Edinburgh where the unelected board have been trying to close the council care homes, and the council has been up in arms about it. In other words there is at least the semblance of democratic tension there. What the Scottish Government is proposing is that the council should have no more say in that.

Once that happens there will be no comeback to these decisions. It will all be decided centrally. So I think that’s why people are very, very worried.

JS: You talked there about outsourcing. One of the issues that I cover on Independence Captured is the way in which the Scottish Government often outsources the design of major national initiatives to private consultancy firms. Do you have any comment on the way in which that has been handled in relation to the National Care Service? For example, the involvement of KPMG?

NK: I think as you say this is part of a much bigger issue. The Scottish Government appears to be permanently outsourcing to the corporate sector. There’s a question about how much of this is driven by the Scottish Government, and how much of this is just down to the generalised corporate capture of government across the board.

But if you’re looking at where KPMG are in the Scottish Government, they have extensive roots. The board of the civil service, which is a small board of half a dozen people, has an ex-KPMG partner on it. The deputy Chief Executive of the NHS, is from KPMG. The head of social care finance in the Scottish Government is also from KPMG. So you can see why they then hand the business of designing the National Care Service to KPMG!

I think the investigation into malpractice at KPMG at a UK level was mentioned in one of your newsletters. We uncovered the fact that Scottish officials were fully aware that the UK Government was investigating KPMG at the time the contract was awarded for the National Care Service.

One of the interesting things about all of this is that the Scottish Government doesn’t even use the Scottish contracts portal to look for advice. If they did, for example, this would enable Scottish universities to bid for the work to design something like the National Care Service. What the Scottish Government do instead is to use UK Cabinet Office commercial contracts, which are specifically designed to use big consultancy firms like KPMG.

So, the Scottish Government are essentially using elements of the UK state to further the outsourcing process. This is not a surprise as the civil service is totally embedded with people moving seamlessly between Edinburgh and London. This creates a big problem.

The Scottish Government has recently denied that they’re getting KPMG to design the National Care Service, despite awarding them a contract to design what they call the “Targeting Operating Model.” While there’s been all this supposed “consultation” work going on, in the meantime, it looks as though the really important stuff is being done behind the scenes via this Target Operating Model.

It doesn’t take a genius to realise that once you involve firms like KPMG any “solutions,” will again promote the private sector. While KPMG have got a certain amount of business interests related to care homes, health as a whole is an even bigger prize. Which takes us back to the health and social care integration agenda. It offers the opportunity to open up a lot of community health services to the private sector, following what’s been going on in England, with the likes of “Virgin healthcare” and so on.

I think there’s a really, really big risk of that now happening in Scotland. I, and those I work alongside with, think that both the NHS and care would be better off separate. We need a democratised NHS, but we also need a democratic care service that is controlled from the bottom up rather than the top down.

JS: Incredible. My last question to you is this. What do you think the key principles of an effective National Care Service would be?

NK: First of all, you need to have an understanding of care. Care is essential to human well-being, indeed to our existence. It’s how children grow up, how we develop to be in adults and how we look after each other. It’s absolutely essential. The starting place needs to be to recognise that under the current social and economic system, a lot of caring relationships get fractured and destroyed and people are left without support.

The state therefore needs to step in and actually provide support to people who need it. So support based on need is fundamental.

But the second part of this is if you recognise that care is about relationships, we need to enable staff working for the care service to actually have the time to form real relationships with people. The idea of just sending care staff round at the beck and call of management to go where they think “care” is most needed that day, along the lines of a “just in time” model, is absolutely no good.

People who need support deserve consistent staffing, and staff who are rewarded appropriately and trained to deal with often very difficult circumstances. A lot of people needing care, for example, have dementia and go through phases of very challenging behaviour. This is very difficult to deal with and requires all sorts of skills and knowledge to do effectively.

So, in summary, we need to have a care system based on need rather than profit. We also need to have a properly trained workforce who can then work in partnership with the people who they are providing care for and to be able to do so with the pay, terms and conditions they deserve.

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