Author: Ron Culley
The importance of local accountability within a national care service
I remember well the first time I arrived on the Isle of Barra, having been appointed as the new IJB Chief Officer for the Western Isles. It’s the archetypal island community – tight-knit; self-sufficient; everyone looking out for each other. I suppose you have to be if you live on the edge of the Atlantic. Almost everyone I spoke to was fiercely protective of their community. Some of the people I met on that first trip talked about decision making in Stornoway (100 miles to the north) as though it were an imperial outrage. I was very quickly disabused of the notion that I could add any value unless I was committed to their community.
I could see why. Local initiatives which had developed organically were an unparalleled success story. One of my favourites was a community garden and café, developed on the back of the hard work of local volunteers and fundraisers. Many of the volunteers had support needs – perhaps they were recovering from drug/alcohol dependency, or they were people with a learning disability or had a mental health problem – and they worked side by side other volunteers and a few salaried members of staff. It was inclusive, participative, and local. It offered people structure and purposefulness and community. It was the stuff of magic.
As the IJB Chief Officer, I was under no illusion that the Western Isles was a natural community – it was to some degree an administrative invention, intended to support efficient local government (and though some might disagree, it broadly achieves that objective). Its communities tended to separate into the constituent islands and sub-divide from there into self-identifying villages and townships. And there-in lies the rub – there is a tension between the aggregation of services to deliver administrative efficiency and the need to ensure natural communities have the resources and powers needed to give expression to their interests and needs.
With a community of around 2,000 people, it wouldn’t make sense for the Isle of Barra to run a social work service or an education service on its own, but that doesn’t mean we can visit service solutions dreamed up elsewhere upon its residents. In my IJB role, I was keen to bridge this gap by establishing empowered locality planning groups across the islands, including one for Barra itself. The integration legislation required that this be done but was silent on the degree to which locality groups were empowered to make real decisions. I was keen to share analyses of how local people utilised health and social care resources. I wanted to promote human rights-based budgeting, the idea being that the community would actively shape the allocation of the resources available to the island in support of the rights of people drawing on health and social care support. In the end, my idealism fell foul of practical bureaucratic accountabilities, the reality of embedded investment (most of the island’s resources paid for the salaries of GPs, nurses, social workers, and so on), and an inability to persuade those around me of its merits.
COSLA has long argued for the principle of subsidiarity, the idea that decision-making should be as local as possible unless there is a value to be had (financial; economic; organisational) from pooling resources and governance arrangements. That is one of the reasons that the idea of a National Care Service is anathema to those who are committed to local democracy in Scotland.
The critique offered is compelling. Already one of the most centralised political systems in Europe, devolution has quickened the pace of public services being made to answer to Scottish Ministers rather than to local elected representatives, resulting in the concentration (rather than diffusion) of power. Police Scotland and Scottish Fire & Rescue are the two most notable examples of regional boards migrating to a national system – but there is no doubt that the administration of public services in Scotland increasingly resides in Edinburgh. In fact, so complete has been this journey that the Feeley review asserted the pre-eminence of ministerial accountability as a self-evident truth. It was a point that didn’t need to be argued or debated because it was so readily accepted and supported by those outside the local government community.
So how have we arrived here? I think in part it can be explained by the devolution process itself and by a creeping frustration from the Scottish Government that its policy objectives can be fragmented or diluted by local delivery. Effective collective and coordinated action by local government matters, in the view of Ministers; in key areas of public service delivery, they want assurance that councils will all do much the same thing because they feel there is a good reason to want everyone in the country to get much the same thing.
Within this context, it is worth noting the development of a rights-based argument about social care, which has been hugely positive, but which is also intrinsically challenging for local authorities. After all, the idea of local accountability implies the freedom of councils to make different decisions and have those tested by local public opinion come election time. The challenge with this model is that minority interests can be ignored (or worse still suppressed) in these situations. If a disabled person finds that their needs are not being met for the want of additional resources, then even with a sympathetic councillor or progressive social worker, the weight of majority expectation might drive local authority budgets towards smooth roads and efficient refuse collection (or so the argument goes. In reality, local authorities have invested much more heavily in social work over the last ten years than in almost any other service, including education).
But when you add the need for local authorities to augment under-pressure budgets with charges for social care services (which, looked through the lens of a rights-based approach, amounts to a tax on disability), and the need for public officials to act as financial gate keepers, sometimes at the expense of the very real needs of local citizens, well you can see why people with support needs have put their energies into supporting a rights-based national service, with universal entitlements enshrined in law. You can see why Feeley was able to assert the pre-eminence of ministerial authority without that principle seeming contentious. You can see why, in the end, local government ran out of friends.
The development of a National Care Service contains two principal shifts recommended by Feeley that takes it from being a local system to a national one. The first is that the duty to assess need will migrate from local authorities to Integration Joint Boards. The second is that Integration Joint Boards will be accountable to Scottish Ministers (via a National Care Board).
The rights-base argument around the process of assessing need within a national system is strong. It speaks to a foundational idea about the value of support – it fires the autonomy of individual human beings; and that can’t be subject to the democratic whim of a council. Why should a person’s entitlement to support vary by area? This is not about deciding whether to invest in play parks or libraries (both valuable community resources) – this is a person’s every-day existence in question, this is about the preconditions of a good life – and that’s not up for debate and can’t be legitimately positioned as a contingent offer. And if a person with support needs wants to move from one part of Scotland to another, is it fair that their entitlements should be re-examined as a result?
That’s not to say, of course, that enshrining that duty to assess need within a national system eliminates the need for the careful management of resources or that it will automatically remove postcode lotteries – assessors will still need to determine whether a person’s needs call for the provision of services and there is plenty of regional variation within our National Health Service. In the end, though, whatever your view on all of this, the political winds have already shaped the outcome – if Feeley is to be realised, it is a done deal that the duty to assess will migrate from local authorities to IJBs.
But if the argument in favour of a rights-based approach to assessing need is settled, we should be careful about how it is situated within a national system of accountability. After all, though we might all rely on the NHS, its governance is hardly picture-perfect. It is performance managed to within an inch of its life. It has a target driven culture that even Sir Harry Burns – otherwise a national hero – couldn’t change. It spews out management data in colossal quantities – but much of it remains unused, left to die at the edge of the data highway. But more than anything else, I don’t think the NHS really understands ‘local’, at least not in terms of governance. Its constituent services might do. GP surgeries have an excellent grasp of local. District nursing teams know communities inside out. But as a public body, the NHS isn’t that interested in local. So, let’s not look to the NHS governance system for our new National Care Service. Let’s invent something better.
One of the Quarriers services of which I’m most proud is the Ruchazie Family Resource Centre. I claim no credit here – it was twenty years in the making and I’m a mere custodian of what it is today: a nursery that acts as a gateway to a plethora of wider support arrangements and signposting for families with lots going on in their lives: financial challenges; substance misuse; mental health problems. It was developed by people on the ground, working with the local community to understand need, to listen to views about what they wanted, which respected their stories and their capabilities. It was cold nights in community halls. It was bureaucratic applications for European funding. It was about starting small (in a neighbourhood flat) and growing (into a family resource centre). It is operated by Quarriers, but it feels like the community owns it. It is also, I fear, uncommissionable, though elements of it are now supported by statutory partners like Glasgow City HSCP. Even the most progressive tender couldn’t bring it into being – it’s classic Christie, built from the bottom up, brick by brick.
Resources like that in Ruchazie are valuable because they connect with people in their everyday lives. The staff who work there get closer to people than even the best community nurses or social workers. During the pandemic, for some people it was their only connection with the outside world. A telephone call would often be enough to fend off the burden of loneliness and isolation. It made all the difference. And having one of our team refer to a local social worker or GP or psychiatric nurse can often bridge the gap to formal support.
So why do resources like the one we have in Ruchazie not exist in every community? I think in part we’ve overstated the role of the statutory bodies in either inhibiting (because of tendering practices or resource decisions) or supporting their development (the magic that I see here and in Barra isn’t something that can be drawn from a statutory duty or legal principle). And when we talk about things like sharing best practice, well it all sounds a bit lame. So, does that condemn us to a fate of patchwork provision, whereby we simply accept the status quo, or at best rely on charismatic local leaders to make the world a better place? That answer, of course, is no.
For me, the magic happens when a series of layers of public services and community resources not only connect but operate as a co-dependency or eco-system: a purposeful and visionary community planning partnership; a local authority that is committed to community development and total place planning – and which has crafted a social contract with its citizens; an IJB that is simultaneously hardwired to the place-making role of the council and which not only allows but actively supports creativity within the third sector; a local third sector that collaborates, takes risks, is imaginative and advances the interests of self-identifying communities; communities which are supported to assert their agency, where a shared purpose can harness the potential of common endeavour; and individuals who are empowered, understand their rights and responsibilities as citizens, and encourage their neighbours and peers to realise those rights.
When these factors align, good things happen. Let’s not kid ourselves about how difficult it is to make all of these things align – but it can be done. East Ayrshire is one good example, with the local authority sitting at the axis of the Community Planning Partnership and encouraging the HSCP to work flexibly with local communities and third sector providers.
South of the border, there are other shining stars. Wigan Council has embarked on a major process of change based on the empowerment of communities through a citizen-led approach to public health and creating a culture which permits staff to redesign how they work in response to the needs of individuals and communities. At the heart of this is an attempt to strike a new social contract between public services and local people that has become known as the ‘Wigan Deal’. To realise this new deal, social workers were given permission to have more open-ended, exploratory conversations with people with support needs, a practice which has since been adopted by other council departments. Innovation was encouraged. Integrated public service offers were developed for Wigan’s various communities. The council moved to a collaborative approach to commissioning in which voluntary and community sector organisations are seen as partners and are actively supported to develop and improve. It has deservedly won recognition as an asset-based approach and has the support of think tanks who endorse the philosophy it espouses.
So, what might local accountability look like within a redesigned National Care Service? Well, the Feeley report already points to some changes. Although IJBs will be situated within a system of national accountability, there is an opportunity to empower the local boards. By formalising the voting rights of those IJB members who were previously disenfranchised – unpaid carer representatives, patient representatives, third sector representatives, GPs, social workers – we may see bolder changes to local health and care systems follow.
And notwithstanding this enlargement of the voter roll, it’s important not to overlook the importance of elected members on IJBs, who can be the most dedicated of public servants and usually have a very good feel for the pulse of the communities they represent. That matters, arguably even more so in a national system. The individual case work of elected members isn’t always recognised – but much is done off-line to remove bureaucratic barriers that impact on their constituents’ lives.
It is therefore important that the local IJBs are empowered and are not servants to the National Board. This needs to be about distributive leadership, not command and control. Ministers need to resist jumping in as soon as something controversial is decided or proposed – because more often than not, that only serves to reinforce the status quo. Yeah, mistakes will happen. Disasters even. But as soon as we go down the road of centralised control, well, that idea of the stars aligning within a locality will very quickly disappear
It is also important that we see the devolution of power from the IJB table to localities. I mentioned earlier the importance of this work, along with its frustrations. Some see locality planning as a further administrative function, and at times national guidance has urged us to map those localities to GP Practices. Although I think primary care is the most important and overlooked part of the NHS, I think that recommendation is a mistake. To develop local accountability, I think that the locality structures have to be able to connect to self-identifying communities. And then they need clear purpose, powers, and budgets to effect change. One of their jobs might be place-making and in doing so recruit third sector bodies as the agents of change. A blended model of community development, seed funding and partnership. Of course, that’ll need free money, perhaps wrenched out of the overall Scottish budget and given to local authorities to pass through, in recognition of their strategic place-making role and local democratic accountability.
And the public bodies which oversee the investment – IJBs and councils in particular – need to be aware of, and mitigate, variation of spend at locality level. I knew from an analysis of health and social care spend on the islands that per capita, spending was higher in Barra than in other localities. And that makes sense – there can scarcely be a more difficult place to deliver public services than on a remote island with a small population. But where variation in spend goes unnoticed, or is noticed and simply accepted, we end up with inequity.
In the end, I think that’s our task, to find a way of delegating meaningful and equitable budgets to locality level, where local people and local professionals become the agents of change within an eco-system of organisations and agencies committed to the public good.
So – choose local. Choose communities knowing who they are. Choose unleashing the innovative potential of the third sector. Choose a fluorescent and fun IJB. Choose giving people a new deal. Choose vegetables from a community garden in Barra.
