The creation of a single police force has paved the way for sweeping changes to how Scotland delivers health and social care.
SHE is 85, lives in a seaside town on the south coast of England, and doesn’t actually exist. But Mrs Smith might soon lead a revolution in Scotland’s neighbourhoods.
Mrs Smith was invented by leaders in Torbay NHS Trust nearly ten years ago when they first started trying to get a handle on how to reform local council and social care services. The complaint was that the one didn’t relate to the other. So, they decided to personalise the issue around an imaginary elderly lady with complex long-term health problems. What would she want?
Mrs Smith’s requests were common sense: she wanted a single point of contact, doctors and social care staff who actually talked to one another, to tell her story just once, and a quick response. Front-line staff wanted it, too. Anthony Farnsworth, chief executive of Torbay Care Trust, notes: “They were saying to the council, and to the NHS, that we could do this better if we were running a single system together, an integrated management structure and put the two budgets together.”
That way, he adds, the system wasn’t just thinking about “Mrs Smith’s health need” and “Mrs Smith’s social care need”, “we were just looking at meeting her needs, whatever they were”. The Mrs Smiths of Torbay these days are promised a more human service. And sleepy Torbay’s practical solutions have now become a benchmark for others to follow.
After another week of constitutional fury at the Scottish Parliament, the polite requests of Scotland’s Mrs Smith have not exactly made the headlines. But, behind the rage, major changes to the country’s public sector landscape are being enacted. As of April, Scotland’s eight police forces will merge into one new national body. And, as we report today, justice secretary Kenny MacAskill told a police conference last week that others might follow. “Where the police are, where they have gone, I think some of my colleagues will learn from. The status quo is not tenable. It was not tenable in the police and it’s not going to be tenable in other forms of public life,” he declared.
Mrs Smith would have pricked up her ears at that. For it looks increasingly as if major changes are on the way to how Scotland’s community services are soon to be run. And, if so, what might the implications be for the councils and NHS chiefs who govern so much of the country’s life?
The case for change in NHS and council services – which together suck up the majority of Scottish Government spending in Scotland – is well-known. In a consultation paper in May on moves to bring together health and social care, Scottish ministers set out the context. Back in the 50s, it noted, in the early days of the welfare state, it made sense for councils and hospitals to work separately. One helped out people in need. The other treated the sick.
These days, however, the division no longer works. As a result of an ageing population and a healthier younger population, the balance of need has shifted markedly towards people in their 70s, 80s and 90s who may not necessarily be sick, but need care and support over longer periods of time. Their needs, therefore, straddle the NHS and local authorities – but the two monoliths don’t connect.
The results will be familiar to many families. “People are too often unnecessarily delayed in hospital when they are clinically ready for discharge,” notes the government’s paper, as Mrs Smith’s transition from NHS patient to social care client gets stuck in bureaucratic treacle. Or, on the other hand, “services required to enable people to stay safely at home are not always available quickly enough, which can lead to avoidable and undesirable admissions to hospital”.
That latter failing means that Scotland currently spends £1.5 billion on elderly people making unplanned visits to A&E wards, a third of the total spend, and more than is spent on elderly social care in its entirety. Most people say they want to remain at home anyway. But at a time of “No Money”, and with Scotland only getting greyer, the necessity for helping them do so is now pressing.
Ministers are, therefore, pressing ahead. Under plans launched by former health secretary Nicola Sturgeon this year, the aim is to remove the barriers between health and social care so that Mrs Smith gets the simple, personalised treatment that she needs in her old age – where the journey from hospital to home doesn’t stop off on the way for a change of driver who doesn’t know the road.
A new bill before parliament intends to bring this about by creating “health and social care partnerships” which, so the theory goes, will bring doctors and social workers together. Councils and health boards will have a duty to integrate their services. Sturgeon’s successor, Alex Neil says he wants “an end to the bureaucratic wrangling” that sees health boards and councils arguing with one another over who should pay for care. Crucially, the reforms are expected to pool budgets and management in order to end such turf wars.
Local authority bosses are behind it. Elma Murray, the chief executive of North Ayrshire Council who represents her fellow 31 chiefs, notes: “Ongoing change has to be a future state. We can’t stand still and the status quo is not an option for any of us. The integration of social care and health is probably the single biggest change for councils since reorganisation in 1996.” She adds: “Decisions should be taken on the basis of the total resource as opposed to your bit of the resource. My view is we should already be doing that.”
But the question is where the change might lead. Neil intends to ensure the new partnerships will get genuine control over money, giving them the clout to build a bridge between the NHS and social care. He, John Swinney and MacAskill sit on a public sector reform committee in the Scottish Government which has agreed to the plans, to take place within the current structure of 32 local authorities.
But blending the work of 32 local authorities together with 15 health boards already sounds difficult. And now there are plenty of questions being asked about why – if such radical changes are being made – shouldn’t the whole structure be ripped up.
As they stand, the Scottish Government’s plans do not envisage a wholesale shake-up of the system, as it has pushed through with the police. Staff will remain employed by one or other body and there are no public plans to rip up boundaries.
But the pressure is on to do so. Recently, Lord Sutherland, whose Royal Commission on long-term care led to the adoption of free personal care for the elderly in Scotland a decade ago, declared the system was “mad”. He added: “It [Scotland] doesn’t need a parliament and Westminster and 32 councils. It means we have 32 directors of social care. It is daft.”
The influential think-tank Reform Scotland has argued that it would be best to wrap health boards up into a new system of 19 local authorities across the country, which would then have responsibility for the lot, overseen with the democratic mandate of local councillors. These new, bigger councils should then be given complete control over council tax bands and rates, to help restore some credibility to local politics in Scotland. (It comes after less than 40 per cent of people turned out to vote in council elections earlier this year).
Or reform could go further. Police chiefs last week suggested it would be best to link in with the new police boundaries, so that the whole of the public sector was working along the same lines. And underneath that layer, argue other bodies, such as the left-wing Reid Foundation, there should be a new layer of local councils which attempt to drive down as much power as possible to the local level.
Comparing Scotland to other European nations, it found that Scots were the least likely to have got involved in local politics. In Norway, one in 84 people stood for election, in Sweden one in 145, while in Scotland the figure is one in 2,071. That, it declares, has left politics as “the preserve of a tiny cadre of professional politicians who are separate from the rest of society”.
The health and social care reforms could now be a trigger for this much wider debate about the make-up of this forgotten part of the country’s democracy. The birth of devolution, and now the build up to the independence referendum, has pushed local government to one side in recent years. But as the government’s reforms kick in, that is now likely to change. Geoff Mawdsley, director of Reform Scotland adds: “We can’t just leave all these things until after the referendum. It shouldn’t be about just saving money, but also about how to deliver better services. And if they raised a bit more of their own money, then they’d have to think about it a bit more.”
Local government leaders appear keen for a debate – although they remain deeply wary of any ministerial attempt to centralise even further. David O’Neill, president of Cosla, the umbrella body for local authorities, says: “Some people in the Scottish Parliament see themselves as running Scottish Regional Council. That isn’t a good idea. I’m not saying that 32 is absolutely right, but if we are going to make changes, then let’s do it on evidence.”
But, for now, ministers may hold back. The view among many is that SNP ministers do not want to open up a can of worms by overhauling local government and health this side of the referendum, especially when the current deal with council leaders has secured for the SNP its most popular policy: the council tax freeze. One well-connected figure says: “Council tax is one of the few powers they can influence, so they aren’t going to give it up until they get something else. And they won’t give up that control until after the referendum.” Ministers and council leaders also point – with plenty of justification – to the cost of structural change, and argue that the claimed cost savings rarely emerge.
That, however, doesn’t knock back the logic of a major overhaul of Scotland’s patchwork system of government. Mrs Smith is waiting.