In the first in a series on the future of Health and Social Care in the four nations of the United Kingdom, Donald Macaskill writes that the recent Feeley Report has given Scotland an ideal map toward a reformed Health and Social Care system, but the proposed National Care Service is a particularly divisive issue. 

In Scotland the last few months have been dominated by an increasingly informed discussion on the future of adult social care. Undeniably the events of the pandemic have increased both the profile of the sector and the urgency to explore the issues that face it. The fruit of a Government established independent commission chaired by a former Chief Executive of the NHS and Social Care in Scotland, Derek Feeley, was published in February and has helped to crystallise the debate.

The Feeley Report (the Independent Review of Adult Social Care in Scotland) has been broadly welcomed not least because it is sensitive to and appreciative of the issues facing those who use services and supports. The review team met with more than 1,000 people, held 128 meetings and 13 engagement events, and received 228 written submissions.

It has certain core elements and emphasises the need for any reform to be rooted in a human rights-based approach which is focussed on those who use supports. It seeks to re-frame the debate so that we begin to recognise social care not as a burden but as a driver for the economy. There is a strong emphasis on prevention and early intervention, on the rights of unpaid carers and on the need to reform the broken system of contracting and commissioning. In its call for wider stakeholders to create a 'social covenant' it outlines the need to develop commissioning models for social good, the importance of introducing fair work terms and conditions, and the necessity of increased spending on social care as an investment. But of all its 50 plus recommendations the one which has gained most attention has been its suggestion to establish a National Care Service.

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The Feeley Report makes clear that there is much to build upon in the establishing of any reform. It is careful not to throw the baby out with the bathwater but asserts that despite good legislation and some progress in the integration of health and social care, that the barriers to implementation have created a gap which has left us with a system which is no longer (if it ever was) fit for purpose.

The suggestion of a National Care Service was taken up by the SNP-led Scottish Government as a key policy in the recent Scottish parliamentary election. There is an ongoing debate about the role of the private sector but this is increasingly combined with a pragmatic awareness that to enable citizens their legal rights of choice, and on grounds of affordability, there needs to continue to be a mixed model of provision at least for the foreseeable future. The National Care Service envisages a body similar to and equal in status with the NHS, under the direct authority of a Minister but with clear leadership from a national board with local delivery in the hands of a reformed Integrated Joint Board system.

Despite widespread approval of the broad principles of as National Care Service from those who use services, providers and the workforce, there has been strong resistance from the local government sector. Perhaps this is not surprising given that the diminution of their role and budgetary control threatens a major plank of both their purpose and value. In true 'turkeys voting for Christmas' style there has been a consistent backlash. What the rhetoric has failed to answer is the decades of under-achievement and the failure and fracture over which successive local authorities have presided. Feeley was clear and his advocates agree that the current system is not working, that power needs to be closer to people who use supports and not retained by the system, whether local or national.

Social care has to be seen as of economic and societal benefit. It cannot be perceived through the lens of clinical or health-oriented models but as a distinctive contribution to personal and individual wellbeing in its own right. A National Care Service needs not to ape its older and bigger 'sister' in the NHS but to assert its own significant voice in the shaping of Scottish society post-Covid. There will be real fiscal, governance and political challenges ahead but there is a very clear desire from the pain of the pandemic to ensure that there is national regulation, a well-resourced and professionalised workforce, an equity of provision regardless of diagnosis and a consistency of quality regardless of provider.

The Feeley Report is not perfect, but it is a helpful start. Its financial analysis is perhaps over-optimistic and there are issues which it does not address. However, for an intensive short and focussed piece of work, it has more than caught the desire to reform, offered the framework of a vision for real change, and it a direction of travel which many of us hope will not be blocked by the vested interest and partisanship of any stakeholders.

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