Iain Gray: Smiling and nodding will not create change

The Westminster coalition is in trouble on the NHS. With health devolved and our two biggest parties agreeing that the NHS in England is being dismantled, and that we want no part of it, we are spectators.

However, as Ralph Waldo Emerson said, “all diseases run into one, old age” and there is a debate in Scotland about delivering social care, especially for the elderly. This week Holyrood’s health committee heard evidence on Scottish Government plans for health and social care, and the whole parliament debated the regulation of care by the care inspectorate. Last week Audit Scotland published a report into the commissioning of social care.

The audit committee, which I convene, have yet to consider the report so anything I say about it is personal.

One of the advantages of devolution is scale. You can get all of the NHS chief executives and their council counterparts in one room. I did exactly that, and we agreed that they would work together to deliver care of the elderly, pool their budgets, commission services together and put service users before service structures. We called it Joint Futures.

Twelve years later Audit Scotland found “limited progress” in joint commissioning and where a commissioning strategy existed it related only to the council. Even then, only 11 out of 32 councils had a proper strategy at all, and only one was long term.

Meanwhile community health partnerships, set up specifically to integrate health and social care, are based solely on the NHS in 29 out of 36 cases according to Audit Scotland.

Frankly, those NHS and local government chiefs saw me coming ten years ago. They smiled, agreed and then carried on with separate budgets, separate staff, separate structures, separate empires. Attention shifted to free personal care when Henry McLeish made that his flagship reform.

Free personal care was important but it distracted politicians and pressure groups from the more profound schisms in how we deliver care, and allowed all parties to rest on the devolved laurels of free personal care ever since.

But this is not just personal because I was the community care minister. My wife’s Aunty Betty was a retired teacher, for whom the word formidable might have been coined, and when she began to fail, she was determined to see her days out in her own home. My wife has many years’ experience as a welfare rights officer. I had been the minister in charge of care. Yet negotiating our way through countless departments of two separate bureaucracies and the private agencies contracted to care for Betty defeated us many times.

A free bathing service is great, but it took weeks to arrange one at all, and when Betty was admitted to hospital it took weeks all over again to get it restarted. The shopping service on which she depended was abolished and it was suggested she might shop online, although by then she only watched one TV channel because she could not change it. Doctors did not communicate with district nurses, never mind with care managers, who did not speak to occupational therapists, and no-one communicated with Betty.

I do not know how anyone in Betty’s position without someone to negotiate the care maze for them manages at all. I fear that many do not.

This is not just institutions defending turf and budgets. It is a clash of cultures too, the NHS’s clinical approach and social work’s more holistic model. The NHS still treats patients without telling them what is doing to them, but social workers sometimes refuse to even suggest a service because the user has not asked for it. The NHS will save your life 24/7, but social work will find someone to take you for a walk and keep life worth living.

This is why you cannot simply move this task wholesale to the NHS or to local authorities. But it is also why they will never integrate if they can help it. At the health committee this week, the professionals were talking about core data sets, collaborative management and integrated resource frameworks. Age Scotland’s submission was about, “the lack of leadership at both councils and health boards…” and the failure to work together which “repeatedly delivered inertia in the journey towards integration”. Nicola Sturgeon needs to understand that the management of the NHS and local authorities are smiling and agreeing again. They will welcome her change fund but they will not change.

This is 12 years more urgent than when I tried. Budgets were rising then, and they are falling now.

Many councils ration care to those assessed as “critical”, on the point of losing their independence for ever.

Early, simple interventions which can delay the onset of dependence are being lost according to Audit Scotland.

More hours of care are provided, but to fewer people, so those who need a little help are not getting it, until they need much more.

We need a national care service, neither NHS nor council but combining the best of the two cultures. We need a national care service as visible as the NHS, which people can access as readily as they do their GP, and which they love and value as much as their local hospital.

The Scottish Government must take on the professionals just as Labour had to do when the NHS was set up. A change fund and integrated resource frameworks will not do it.

• Iain Gray is Labour MSP for East Lothian and a former Scottish executive minister