This document discusses the crisis in social care provision in Scotland. It provides context on the history and development of care services from the creation of the welfare state to current issues. Key points include: - Care services have historically been underfunded compared to the NHS and focused on physical needs rather than a holistic understanding of care. - Marketization and outsourcing of care from the 1980s onward, coupled with budget cuts, has financialized and degraded the care sector. - Integration of health and social care, while intended to help, has in practice subsumed social care under health priorities and management approaches. - The current system is characterized by underfunding, a burnt-out workforce, and a focus

1. Care in Crisis
Nick Kempe
Convener Common Weal Care Reform Group

2. What is care?
Neither the Independent Review of Adult Social Care nor the
Scottish Government have attempted to answer the
question - Feeley talked of social care support
“To feel concern or interest about another person, to do
things that help or protect them” (my go at a definition!)
Care ethics
“a practice, rather than a set of rules or principles …”
(Joan Tronto Moral Boundaries 1993)

3. Understanding Care
• Embedded in everyday life: kindness in the street, neighbours, friends,
family, community
• Relational and reciprocal: “co-produced” between carer and cared for
person
• Care needs arise from being human, are both mental and physical, and are
central for human development and survival (from baby to adulthood)
• How care needs are met has a major impact on health needs
• Ability to form caring relationships is learned through caring relationships
• “Additional” care needs may arise e.g from disabilities, social disadvantage
• Care needs are also socially determined
• Caring is irredeemably complex (from conflicting feelings to abuse)

4. But care also goes wrong……………
• We all have our “off” days
• Giving without receiving is challenging and stressful (most parents will
experience the feeling of being at their wits end)
• Poverty has a major impact on people’s ability to care and caring
relationships e.g time to look after children, space to look older people,
homelessness
• Many social problems have their origins in a lack of care or care going
wrong: drug addiction, suicide, homelessness, loneliness etc
• Some people grow not to care (from individual psychopaths to war) or
(paradoxically) define their caring identity in part through fear or hatred of
others.
• In extremis, the caring relationships that hold society together can collapse
as people fight to survive

5. The case for care provision and social work
Our value assumption, which has been under attack for some time, is any
worthwhile society is sustained by and dependant on the care people show
for each other. Arising out of this:
• Care services should be about meeting care needs which would otherwise
be unmet
• Social work’s role is to help people whose care needs are unmet or are
facing difficulties in their caring relationships
• Support for informal carers should be an integral part of care provision
• We need a wider public care function
Social work and care work are intimately connected, a fact that is often
forgotten, and both to make a difference require workers to form positive
relationships with those they work with.

7. An indication of the crisis - Scotland’s death
toll
• Covid Deaths 2,242 investigated by crown prosecution service
• 2021 753 suicides
• 2021 1,330 drugs
• 2021 250 homeless
• 2021 1245 alcohol
• By comparison 2021 141 road traffic accidents

8. A little history
1920. Rejected charity as the means to serve citizens
in need and called for approach
“grounded in social justice and citizenship, replacing
generosity with justice, benevolence with duty,
condescension with respect”.
Became a lecturer in Social Work at London School of
Economics prior to entering politics

9. The creation of the welfare state
• 1945 Family Allowances Act
• 1946 National Insurance Act
• 1946 National Insurance (Industrial
Injuries) Act
• 1946 National Health Service Act
(implemented July 1948)
• 1948 National Assistance Act
• 1948 Children Act
• 1949 Housing Act
• 1949 Legal Aid and Advice Act
Based on Social Insurance and Allied
Services, better known as the
Beveridge Report compiled by
William Beveridge, a liberal.
A plan to put an end to 'five giants’: -
Want (poverty), Disease, Ignorance,
Squalor & Idleness (unemployment).
A two tier system when it came to
addressing poverty, first tier National
Insurance, second tier National
Assistance.

10. A National Health Service founded on need
Need before resource
‘it has been the firm conclusion of all parties that money ought not to be permitted to stand in the way
of obtaining an efficient health service’ (Nye Bevan introducing NHS Bill 1946)
‘access to NHS services is based on clinical need’ (NHS constitution – survives to this day)
Professional autonomy for doctors
‘My job is to give you all the facilities, resources and help I can, and then to leave you alone as
professional men and women to use your skill and judgement without hindrance’. Nye Bevan letter to
doctors on creation NHS.
Although there were no extra resources provided on day 1 of NHS, clinical need has since driven its
development.

11. Care provision - at the back of the welfare queue
For the “residual groups” (Bevan), the “handicapped” (old and
disabled) – the priority was the abolition of the workhouse.
Responsibilities for welfare (including accommodation) were given to
local authorities, responsibilities for income (welfare benefits) to the
National Assistance Board.
Resource before need
‘The extent to which we can carry them out will depend on our
resources’ (Bevan)
No professional autonomy
Social Workers were not recognised like doctors

13. Strengthening social work and social care
Social Work (Scotland) Act 1968
• “duty of every local authority to promote social welfare by making available advice,
guidance and assistance on such a scale as may be appropriate for their area”
• Creates duty to assess the needs of people who might need services
• Unifies social work profession & creates role Chief Social Work Officer
• Creates children’s hearing system
Chronically Sick and Disabled Person’s Act 1970 (Alf Morris)
• Introduces general duties to make buildings, toilets etc accessible
• Creates duty councils provide a wide range of services (recreational, educational as well
as personal care) if “it is necessary”. After years of piecemeal approaches to services n,
Gloucester v Barry House of Lords 1997 confirmed councils could ‘take their resources into
account’ when deciding if it would be ‘necessary to meet a need’.

14. The marketisation of care provision c1980 on
Key elements
• State funding for private care homes led to huge expansion 1980s
• NHS and Community Care Act 1993
• Duty to plan for services »» commissioning and outsourcing
• Replacement fixed charges by means test
• Service provision dependent on assessment – social workers into gatekeepers
• Ideology that care is a commodity anyone should have a right to buy -
Direct Payments Act 1996 allows people take cash to buy own services
• Insufficient budgets, including income streams transferred from central
government and NHS, drives outsourcing services

16. Health, the NHS and care provision
• Success of welfare state, coupled with other societal changes, drives
up demand for care provision
• Closure long-stay NHS institutions (mental health, learning disability,
older people) achieved by “resource transfer” monies to fund
alternatives in community - but transfers long-term financial
responsibility from NHS
• Accompanied by reduction acute hospital capacity – “just in time”
medical treatment – which puts political focus on “delayed discharge”
• “Integration” health and social care seen as solution to problems

17. Managerialism
Key elements (developed under Tony Blair labour government)
• Budget management replaces welfare (accountants v social workers)
• Risk not need (development eligibility criteria, “protection”)
• Focus on improvement and performance of public services, driven by
assumption that it is possible to do more with less
• Proceduralisation and centralisation of social work
• Proceduralisation of care provision through regulation (Scottish Social
Services Council and Care Inspectorate)
• Central government turns to private sector for “ideas”/solutions

18. Characteristics of social work and care sector
on eve of Covid pandemic
• Almost 15 years of real terms budget cuts while demand growing
• Financialisation of care sector and extraction profits
• Collapse of community based and preventive services
• A grossly undertrained and underpaid workforce (driven by EU derived
procurement regimes
• Perverse “rationing”/resource allocation eg time and task home help visits
• Increasingly centralised and unaccountable management (Health and
Social Care Partnerships)
• Policy dominated by requirements NHS and individualised approaches to
care (rights within a market rather than collective need)

20. The Scottish Parliament and care provision
Good intentions with unintended consequences
• Free Personal and Nursing Care – narrows provision to physical needs
• Adults with Incapacity – “blocked beds”
• Care Standards – favour private provides with access to capital
• Regulation – become focussed on process not outcomes and
disciplining the workforce
• Self Directed Support Act – embeds market (choice) NOT control
• Joint working – adult care subsumed under health

21. Integration and the crisis in IJBs/HSCPs
• Financial
• Lack of funding: if vacancies, £5.8m NHS and £5.3 Council, filled EIJB bust.
£25m initial deficit
• Budget lines control everything; Drumbrae & mileage examples
• Unmet needs -no data (but EAP 750 instances of unmet need ~ 7500 hours).
• Democratic
• Board (only members with any independent power are councillors)
• Stakeholders
• Workforce – understaffed, abused and burnt out (sickness levels)
• Values – neoliberal; little public service ethos left

22. The external pressures on the EIJB
• Scottish Government failure to progress Fair Work
• Lothian Health Board (agree pay for Drumbrae if more beds axed)
• The Scottish Government’s Edinburgh Assistance Programme
• e.g Scrap local offices (only four) for functional model
• Care Inspectorate – recent report on Adult Protection focusses on
process not outcomes
• Audit Scotland Best Value Assurance report 2020 (must do more with
less)

23. Contradictions in the system – an opportunity
• Board Members as (elected) representatives v(elected) managers?
• Shortages of home care staff but cannot increase mileage remote
• 3 Conversations Model v Social Care Direct
• 3 Conversations model v Total Mobile and Command Centres
• GPs accessible and overwhelmed – social workers remote

24. What can be done?
• Use the pause in the NCS Bill to articulate a different type of Care Service
• Campaign for “co-design” and planning to start locally from bottom up
• Unionise
• Press for increased transparency and democratic accountability
• Press for collection and reporting of data on unmet need
• Reduce the role of the private sector, reinvesting profits in the workforce
• Devolve services and power to the front-line, putting the focus on
relationships