What next for Scotland's National Care Service reform?

All three candidates have voiced differing preferences for its future, from rethinking it (Forbes), pausing it (Regan), or compromising on it (Yousaf).

For those on the social care frontline, alarm bells are sounding.

Speaking during a conference on the future of social care this week, Rachel Cackett, chief executive of the Coalition of Care and Support Providers, said: “If this delay is going to happen then at CCPS we welcome this, as long as the additional time is used to improve the Bill and is not just a pause for the leadership election.

“Or is it a void in which the need for social care reform sinks, yet again, into the shadows?

"One of the examples that’s been given to us very strongly has been a real concern that this could go the way of Dilnot.”

READ MORE: Nearly 7000 Scots still waiting two years for NHS ops as number falls to 1,400 in England

The Dilnot report recommended a raft of social care reforms for England back in 2011, including a cap on lifetime contributions which would mean no one paying more than £35,000 in total towards their care, with costs fully funded by the state thereafter.

Initial optimism gave way to dithering, however, and the plans were eventually shelved.

Instead, from October 2023 England will introduce an £86,000 cap on care costs and raise the capital threshold at which people are exempt from care home charges to £100,000 (most will still have to contribute up to £200 a week for food and accommodation costs, however, and anyone with assets over £20,000 will also have to pay a further £200 per week under ‘tariff income’ rules).

Sir Andrew Dilnot warned that the move will unfairly benefit wealthier pensioners at the expense of the poorest.

Sir Andrew Dilnot, the Welsh economist and former director for the Institute for Fiscal Studies, whose 2011 report on social care was initially hailed as a watershed moment (Image: UK Government)

The saga is a reminder that social care reform is a Gordian knot for politicians: a complex problem with a seemingly simple solution (more funding) that nonetheless seems impossible to deliver.

In Scotland, the National Care Service (NCS) isn’t even grappling with the question of care charges - at least for now.

By 2022, a self-funded care home resident in Scotland was paying an average of £1,200 a week with nursing, or £1,077 a week without nursing.

Both costs are more than 70 per cent higher than they were a decade ago, and around 40% higher than the charges levied on local authorities for council-funded residents.

Anyone with capital over £29,750 in Scotland must pay their own care home costs in full.

Care home charges have steadily increased, with care costs subsidised by self-funders (Image: PHS)

While the NCS Bill clearly signals that further rounds of secondary legislation may alter the charging and eligibility criteria for care costs, that is a negotiation deferred for another day.

Free personal care for over-65s who need help with activities such as washing, dressing, mealtimes, and medications remains free, as it has been since 2001, but other needs - such as help with housework or shopping - continue to be means-tested.

As it stands, the NCS legislation is primarily geared towards creating a national body that would set standards and priorities, transfer responsibility for delivering social care from councils to new ‘care boards’ , and make ministers directly accountable.

The idea is also to iron out a much criticised “postcode lottery” in charges and availability for social care, with more consistent and improved pay and conditions.

READ MORE: SNP reforms may make social care worse, MSPs told

There are mounting concerns, however, that the costs of this structural reform could spiral out of control while doing nothing to solve the entrenched recruitment and retention crisis that is leaving so many providers in peril.

Implementing the Bill by 2027 will cost an estimated £664 million to £1.26 billion, excluding any additional costs that may come, for example, from much-needed pay increases for social care staff.

As Audit Scotland put it somewhat ominously last week, the overhaul represents a “significant unknown financial commitment” for the health and care budget.

Some critics have argued that the whole endeavour should be scrapped and the money diverted into improving the service as it stands.

One urgent priority must surely be to close, or at least narrow, the gap in pay between NHS and social care staff.

From April 2023, if current pay proposals are accepted, an adult social care worker in Scotland on a minimum £10.90 per hour will be earning 20% less than a Band 3 healthcare support worker in the NHS: £21,225 per year versus £25,468, where both are full-time.

The difference in pay between social care and Band 3 NHS staff could be 20 per cent in 2023, compared to 7 per cent in 2018 (Image: PHS)

With such a large, and widening, discrepancy many fear that the NHS - with its own vacancy problems - will become like a magnet for exhausted and demoralised social care workers.

Dr Donald Macaskill, chief executive of Scottish Care, said the pause in NCS legislation was "an opportunity to rescue social care from the state of collapse that it’s in".

Also speaking at the Scottish Policy Conference on social care, he added: "Every week I’m getting a provider of social care in the community or in care home provision phoning up to say ‘I don’t think we’re going to survive beyond the Spring’.

"Be in no doubt that the obscenity of the [pay] difference between a basic new entry healthcare worker into the NHS and somebody with experience working in social care - unless we close that gap, we will not have, in my case, the 400 organisations providing care and support to citizens who need that care.”

READ MORE: What will happen now to the poor souls on care home waiting lists?

It is also imperative, said Ms Cackett, that social care is valued as an end in itself rather than something that exists solely "to stop the NHS falling over" by "reducing A&E wait times or supporting people’s discharge from hospital".

This year, one in 25 people in Scotland, of all ages, will require some form of social care. Many more of us will depend on it in future.

So what will NCS be: another missed opportunity, or the start of a turnaround?