CRITICISING the Scottish government’s national care service Bill is easy. Everyone does it. Including these days even the Scottish government, which has announced that it is abandoning key principles of its own legislation. The real challenge is in outlining an alternative. This is what Unison Scotland has done in commissioning our new report Towards A Real National Care Service. 

We’ve called the report A Real National Care Service to make a clear distinction from the Scottish government’s plans, which more resemble — as one delegate to STUC Congress put it — “ a press release that’s grown out of control.”  

The Scottish government intended removing all of social work and social care and an unspecified set of health services from local government and the NHS, to be given to ministerially appointed quangos. These wouldn’t deliver services but instead commission and procure services in a market. 

The Scottish government has since been forced to back down on its plans for wholesale transfer of staff and assets from councils and the NHS. What it intends to do now, though, is far from clear. Unison Scotland freedom of information requests are given responses with all of the relevant information redacted. The Scottish Parliament committee considering the Bill has had to pause its work until such times as the Scottish government answers a long list of questions.

The need to outline a different way forward, one that will address the crisis in care is urgent. That is why Unison commissioned our report from APSE — the Association of Public Service Excellence.

Our starting point is not that of the Scottish government which believes that progress will be delivered by “a vibrant market.” We believe it is advance of market mechanisms and the values that approach enables and encourages that lie at the root of the crisis. Without tackling that, putting more resources into the system, although necessary, won’t provide a lasting solution. 

A major expansion of publicly owned and operated provision, is what we need. This would begin to challenge the private, resource extraction-based model, creating a financially transparent alternative to the private market.

The Feeley review came out against what it calls “nationalisation,” saying that taking care provision into public ownership would be too expensive, but made little attempt to look at what the costs would actually be. 

Feeley suggests that the capital costs would be the stumbling block. This ignores that the public sector has access to much cheaper capital than the private sector.

What would be an extra cost is the increase in staff costs associated with public-sector pay rates and pensions. All other elements of running costs are likely to be lower or around the same, with some significant drains on resources — payouts to shareholders — disappearing altogether.  

Something in excess of 20 per cent of income leaks from the care system to the owners and financiers of the operator. To this can be added the loss of tax revenue to the state through companies’ use of “tax efficient” structures.  

In these circumstances the higher staffing cost publicly provided alternative could be far more price competitive than some people are willing to admit. Particularly when all the “hidden” additional costs of using private providers are accounted for (procurement, contract management, supplier failure etc).  We shouldn’t forget either the “propping up” of low pay in private care providers via in-work benefits is another hidden cost the public pay for the current system.   

On a business case by business case basis, local authorities are in fact well placed to develop existing or new services. Public provision would save the public purse millions of pounds.

The interdependency of health and social care is well understood. A large part of the cost of expanding public provision could be offset by genuine efficiency gains. Just increasing the level of care to a level that would allow the timely discharge of elderly hospital patients would save the public purse many millions of pounds in delayed discharge costs.

A national care service without a renewal of public-sector provision will miss a major opportunity to move away from a market that increasingly works at the expense of the Scottish public and economy. Allowing a market model to continue, as the Scottish government intend, will retain pressure on companies at the delivery level to follow a lowest-cost model. 

We can do better and this report gives a practical demonstration of how. 

The report Towards a Real National Care Service can be found on the Unison Scotland website here.