With the end of the NCS, Susan Galloway sets out the union alternative for national care, backed by UNISON and the wider union movement

The NCS has been abandoned. After £28 million of public investment, the remaining vestige of any new national institutional structure will be dropped from the bill when (if) it progresses to Stage Two. Instead, there will likely be some reforms to Independent Joint Boards, the partnerships between health boards and local authorities which plan and fund health and social care services.¹

“So what now?” is the reasonable challenge made in the Disabled People’s Movement open letter of November 2024. Having been promised so much (in return for much needed support) the anger of Disabled People’s Organisations is understandable.

However, the abandoned NCS plan did not deliver the kind of NCS we desperately need, as the open letter claims. It was never “a 1948 moment”. A universal, comprehensive, needs-based model of social care, free at the point of use and eliminating profit from care, was not on offer. Indeed, this option was explicitly rejected by the Independent Review of Adult Social Care in Scotland (IRASC) and was not likely to be delivered by KPMG, the outsourcing giant awarded the £0.5 million contract to design the NCS operating system.² Wholesale reform is needed but it must be the right kind. The actions most needed to improve things for care users and the workforce are not contingent upon reviving the abandoned bill.

It is also false, as the open letter states, that trade unions have “buried their heads in the sand, withdrawing their support for the National Care Service Bill: offering no alternative proposals.” In 2023 UNISON published its alternative vision for an NCS,³ shortly followed by “Towards a REAL National Care Service for Scotland”.⁴ This report makes the case for an NCS based on NHS principles, explains how it is both affordable and achievable, and sets out first steps on a longer path towards it. UNISON is also pressing for fundamental change to Care Management, the process by which care needs are assessed. This was not even considered by IRASC, despite being central to how disabled people and their families experience the system. UNISON’s 2024 Care Management report makes the case for reform that builds on the common cause between those who need and depend upon care and those who provide, assess and deliver support.⁵

Care Market Myths

The prolonged crisis in our social services system stems from years of chronic underfunding and the deeply fragmented market model of care provision introduced by Thatcher’s government and extended since by UK and Scottish governments. The market is failing, particularly in rural and island areas. Meanwhile a shift from hospital to community-based care has been simultaneous with the privatisation of NHS services. Specialist dementia care and intermediate care (‘step up, step down’) are in many areas now wholly or partly outsourced to the private care sector.⁶

The best way to achieve stable, secure and sustainable local care services is through planned expansion of publicly provided care, and improvement of pay, conditions and job quality. The fastest route to this is insourcing, notwithstanding the need to improve public sector conditions to address staffing difficulties. Establishing sectoral bargaining in third and private sector care is another route. UNISON is leading on this front too. Care workers are being empowered through collective organisation and bargaining. Without recruiting and retaining workers there is no care.

UNISON’s alternative would change both the model and the financial environment, replacing rather than bolstering the market, and reducing reliance on private providers. In contrast, the government’s NCS plans were based on IRASC’s flawed diagnosis. IRASC held that the current market system could successfully deliver needs-based care providing there was stronger (and more punitive) central direction, with services accountable to government ministers (bypassing councils), and more ‘rigorous’ management of the care market to deliver social benefits like ‘Fair Work’ (through ‘ethical’ procurement). In truth, these would never have delivered the scale of transformation promised to disabled people or the workforce, particularly in the current fiscal climate. The government was unable to convince the vast majority of professional organisations and public bodies otherwise. Crucially, apart from budgeting for breaks for carers, the cost of meeting current and projected care needs was not assessed for the purposes of the bill.    Crisis-Driven Care

Before going further, it is useful to ground this in some facts about the scale of underfunding, the extent of profit from care, and, unless there is a break with austerity economics, the even deeper crisis of unmet need that is in store. Rising demand for adult social care is the single greatest pressure on IJB budgets,⁷ due not only to an ageing population (the number of over 65s will rise by a third over the next 20 years) but to the impact on population health of almost two decades of austerity.⁸ Public funding is not meeting demand. IJBs had a combined ‘budget deficit’ of £357m in 2023/24. That deficit is growing substantially year on year. A shift towards home-based support has been achieved, but resources are concentrated on fewer people with the greatest needs.⁹ Assessment of care needs conducted by overstretched social work services is hugely bureaucratic and dictated by budgets. Crisis-led, it is a rationing system.¹⁰ Cuts to services and budgets are the main reason for the desperate situation the open letter sets out.

The standard way to manage the ‘budget gap’ is by intentionally not meeting need: changes to eligibility criteria, recruitment freezes, waiting lists, cuts to budgets for residential care places. IJBs rely on not filling vacancies – understaffing – to balance budgets.¹¹ Social work services are so overstretched that almost 6,000 people were waiting to receive a social care assessment in October 2024. More than 3,000 people were waiting to receive care at home after being assessed. Thousands more do not meet the thresholds. This has economic consequences. The number of unpaid carers increased by a quarter over the past decade and is a factor in the contraction of the workforce.12 In areas of social care not delegated to IJBs, councils have protected spending over the last decade. But with vastly reduced budgets, this has come at the expense of severe cuts to other local services, such as cleansing and environmental health.¹³

The private sector dominates residential care (providing 79% of care places) and is now the largest type of provider in care at home.¹⁴ Cera Care Group, the largest private provider of homecare in Scotland with over 1,000 staff, is a rapidly growing European company funded through private equity investors. The fact that both care at home and residential care remain attractive to private equity investors is prima facie evidence of profitability. Recent analysis for Edinburgh IJB shows evidence of ‘price gouging’ by private care operators from 2022 onwards in a city with a scarcity of care beds.¹⁵ Simply increasing public funding will not resolve the crisis unless the extraction of that funding in private profit and dividends is also stopped.

Bringing Care Home

Resources are being removed from frontline care through the additional costs inherent in a market system and through reliance on private providers. Market failure means that in practice ‘choice’ is illusory as providers exit or collapse leaving individuals without services they need and public bodies carrying the cost of picking up the pieces.¹⁶ Services which are funded by the public should be publicly accountable and there is considerable risk involved in external organisations with independent interests dominating service provision. The recent actions of one the UK’s largest care companies bear this out.¹⁷ In 2021 HC-One, announced the closure of 52 of its 328 care homes, five of these in the Highland region, with a further 19 closures announced in 2023 as the company ‘repositioned’ itself in the care industry. For some remote rural areas affected it meant the potential loss of the only local nursing care home. To secure provision and avoid out-of-area placements, Highland Council and NHS Highland purchased the HC-One care home in Lochaber (in 2024) while HC-One’s Campbeltown nursing home was bought by Argyll & Bute Council (2023). The HC-One staff in each case transferred, to their benefit, to employment by the council and NHS. Just last year HC-One handed back the contract to deliver specialist dementia care (HBCCC) in Lanarkshire, creating huge anxiety for residents in the now-closed units at its Bellshill care home. It is significant that these were NHS services outsourced by the health board a number of years ago, initially to BUPA, and now brought back in-house.

The purchase of care homes coming onto the market is one way to start rebalancing care provision, as UNISON has outlined. Other options are to take contracts back in-house as they come to an end, or to invest in developing brand new in-house care capacity. The opening of new public care provision in the Western Isles in 2024 and in Fife, where the HSCP’s latest ‘intergenerational care village’ opened in Methil in 2023, provides stability and resilience against risk through direct control of provision. Achieving a higher standard of care quality is another key driver for insourcing. Along with security and stability this was the main reason for North Ayrshire IJB deciding to bring its final remaining home care contracts in-house. Completed in 2024, this in-sourcing means that all care at home services are now publicly delivered in North Ayrshire, with the staff of three contractors successfully transferring to council employment.

The rebalancing of care provision is not only vital to regain stability and sustainability. The renewal of direct public provision is an important step towards achieving the type of National Care Service that the public supports. But this shouldn’t be a piecemeal process, picking up the pieces only when providers fail or hand back contracts. UNISON argues that we need a plan for expanding the core of publicly provided provision and raising standards, job quality and reward in the social care sector. This in turn will help improve the quality of care. At the same time, UNISON believes that we must reform social work and address managerialism, to make it a prevention-focused community service supporting people through relationships.¹⁸

These should be central aims of national government policy backed by a coordinated national strategy that makes resources available to local areas (IJBs/councils/NHS boards) to support insourcing of care. Social care is a community service and needs to be planned and coordinated locally, with the full involvement of care users through properly resourced elected councils, and delivered accountably by the public and voluntary sector. Within this model, care users can be empowered to make decisions about their care and the systems and services. This type of model is being developed by the Welsh Government. We can do the same.

Susan Galloway works in UNISON Scotland’s policy team and worked closely on the National Care Service Bill. She writes in a personal capacity.

1. Ministers had already been forced to abandon their original preferred model NCS, which would have transferred over 70,000 staff out of councils, announced in December 2023 (See UNISON Scotland Policy Briefing 139). ↩︎
2. IRASC argued that removing private provision was unaffordable and that type of provider makes no difference to the quality of social care services (disproved by the STUC’s 2022 research report, Profiting from Care). ↩︎
3. UNISON-Vision-for-a-National-Care-Service-.pdf ↩︎
4. Towards a REAL National Care Service – summary report. ↩︎
5. Care Management: Fit for purpose? ↩︎
6. Hospital Based Complex Clinical Care (HBCCC) ↩︎
7. National Benchmarking Overview Report 2022-23 ↩︎
8. Chik Collins, Director GCPH, evidence to Health, Social Care & Sport Committee, 10 Sept 2024, Official Report pp21-44. See also https://www.scotlandscensus.gov.uk/2022-results/scotland-s-census-2022-health-disability-and-unpaid-care/ ↩︎
9. Integration Joint Boards’ Finance and performance 2024 | Audit Scotland ↩︎
10. Care Management: Fit for purpose? ↩︎
11. Integration Joint Boards’ Finance and performance 2024 p.16 ↩︎
12. https://www.scotlandscensus.gov.uk/2022-results/scotland-s-census-2022-health-disability-and-unpaid-care/ ↩︎
13. UNISON Scotland Policy Briefing 146. Since 2013/14, the Scottish Government budget has increased by 37% in real terms. The real terms increase in the local government budget over the same period was 1.3%. National Benchmarking Overview Report 2022-23. ↩︎
14. Care Inspectorate, Quarterly Statistical Summary Reports. Quarterly Statistical Summary Report – Qtr 4 (2016/17) CI_Stats_Report_Qtr2_24_25.pdf ↩︎
15. Edinburgh IJB, public papers, 17 June 2024. pp169-196. It concluded: “even the most expensive scenario using Council homes…is less costly than purchasing care home services…from the independent sector at the prevailing fee.” ↩︎
16. The required notice period is 13 weeks. ↩︎
17. HC-One’s Home Farm Care Home on Skye was taken under NHS Highland supervision during the Covid-19 pandemic, and subsequently into public ownership, due to exceptional number of residents’ deaths. ↩︎
18. Colin Turbett, Assessment and Care Management: its history and context within social work in Scotland today. (2024: UNISON, SWS, SASW). ↩︎