Iain Ferguson considers the flaws of the now-failed Bill and what the latest policy-shift means for the vision of profit-free care.
The Scottish Government’s decision to drop its proposals for a National Care Service has huge political implications. The National Care Service was presented by then-First Minister Nicola Sturgeon in 2021 as “the most ambitious reform of the devolution era”. It was the government’s flagship policy. On top of Humza Yusaf’s resignation, the criminal investigation into Sturgeon and her husband, and the loss of 39 Westminster seats in the 2024 election, it adds to the sense that the SNP’s government is on the ropes.
More important than the implications for the SNP are the material implications for all who rely on a social care system facing crisis. Not that the proposed Bill would have resolved that crisis. Roz Foyer, General Secretary of the Scottish Trade Union Congress, summed up many care sector workers’ feelings when she argued at the 2024 STUC Annual Congress that the Bill “does nothing to address the key weaknesses within the current system – low pay, insecure conditions, chronic staff retention and a complete overdependence on highly financialised, profit-driven providers.”
The vision of a new National Care System — universal, properly funded, free at the point of use and offering choice and control — had potential to unite and inspire service users, care workers and informal carers. For many disabled people, its collapse will mean the continuation of business as usual in the form of 15-minute ‘care’ visits by underpaid care workers, informal carers being pushed beyond exhaustion, and service users being left alone and unsupported. It will add to a sense of individual and collective despair and hopelessness, which the far right can tap into to scapegoat ‘undeserving’ users of social care.
Why Did the Bill Fail?
The Bill failed to address the root causes of the crisis in social care. Indeed, as critiques from Common Weal, UNISON and Social Work Scotland have pointed out, its provisions had the potential to make these problems worse. Take the domination of residential social care by the private sector. As we argued in a 2021 pamphlet produced by the Social Work Action Network and the Jimmy Reid Foundation:
More than 60% of residential care in Scotland is currently in the hands of private for-profit providers, a proportion that has risen over the last decade. And while the majority of these are small businesses it is the big global healthcare providers such as Four Seasons and HC One, through their access to sources of finance and their ability to offer economies of scale, which shape the market. A report by the Institute for Public Policy Research in 2019 found that private providers offered less training, had lower pay and higher staff turnover than Third Sector or Local Authority-run homes. So it is perhaps not surprising that homes owned by the giant HC One in Scotland saw such a high number of deaths during the pandemic.
The problem is not simply the poorer quality of private sector care or the fact that profit should have no place in social care provision.
These providers, dependent on global market forces, build massive instability into the system. Not only was nationalisation of social care never seriously considered by the Scottish Government, but the Bill justified private care with the statement that “services provided by the National Care Service must be financially stable in order to give people long-term security”. Yet in 2019, Britain’s four biggest care home providers were up for sale and struggling to find buyers. The performance of Southern Cross, Four Seasons and H-C One, never mind smaller providers such as Bield Housing (whose slogan prior to announcing the closure of twelve residential homes in 2017 was ‘A Home for Life’), demonstrate that financial stability is precisely what market-driven care does not provide.
That same unwillingness to challenge market forces is reflected in the Bill’s proposals for homecare services. Many problems in the home care sector – low pay, poor training, 15-minute visits – are products of a system where services are outsourced to private providers or third sector organisations which win contracts by keeping costs as low as possible. That outsourcing model underpins the Bill’s provisions.
One casualty of market-driven social care has been good quality social work. Rather than being based in communities and doing relationship-based work they are trained for, social workers have become risk assessors and budget managers, implementing ‘eligibility criteria’ which ensure that only those with ‘critical’ needs receive a service. The Bill was silent on social workers’ roles within the new care system.
Indeed, the Bill was silent on most key issues concerning those involved with social care. As UNISON rightly noted:
The Bill is so lacking in detail that it is difficult to evaluate many of its provisions. From the number of care boards to the pension rights of transferred staff. From what services might be transferred from the NHS to what an independent advocacy service of the national complaints service would look like – none of these details are available. Nor can there be their significant parliamentary scrutiny of proposals once details become available – they will be presented as secondary legislation which cannot be amended.
The reference to Care Boards highlights the most contentious aspect of the Bill, at least as far as COSLA, the organisation representing local authorities, was concerned. The Bill would have transferred all social care matters – and up to 75,000 social work and social staff – to new Care Bodies whose members would not be elected but appointed by the Minister. Of a piece with the SNP government’s well-established fondness for centralising services (think Police Scotland), it represented an assault on local democracy.
Confronting Cowardice
The contention highlighted a deeper problem. For decades, local authorities — whether Tory, Labour, or SNP—controlled — have mis erably failed to protect local social care services. Instead, they have implemented Tory cuts passed on by the Scottish Government. It is scarcely surprising that disabled people, the biggest single group of users of social care in Scotland, have no confidence whatsoever in the capacity or willingness of these same local authorities to deliver a transformed social care service. In the statement issued by leaders of the seven main disability organisations in Scotland, they highlighted that social care is not only needed to support them with basic tasks, but to enable them to live a purposeful life, within their family and community-at-large. Even for those who do get social care, they are charged exorbitant fees, which plunge them further into poverty. This is why we need a National Care Service and fundamental reforms to the broken systems.
They are right to be angry and to stress the urgent need for change.
Good intentions are not enough, whether from politicians or civil servants like Derek Feeley, chair of the IRACS review, who confessed:
We share the unease about whether it is right – in a country committed to healthcare free at the point of need – to all of its citizens, regardless of age or any other characteristic – that an important part of our care system is largely run on a profit-making business.
Unfortunately, Feeney’s unease did not move him to propose removing the profit motive from social care. But the end of the Bill means the fight for a different kind of social care system in Scotland falls to the trade unions, disability organisations and to the wider Left. A call from the STUC for a conference of trade unionists in the social care sector, service user organisations, and carers, would be a good starting point.
Iain Ferguson is the author of Politics of the Mind: Marxism and Mental Distress (2nd edition, Bookmarks, 2023) and a long-standing member of the Socialist Workers Party.