How do you fix the NHS? Part 1: The social care crisis

NO POLITICIAN FOR A GENERATION has been able to answer the question: how do you solve a problem like the NHS? This is the first of four articles considering why we spend more on healthcare, yet outcomes fail to improve.

Part of the solution is efficiency, as demonstrated by research from Reformer Pal Chidambaram of the Scottish Cardiac Audit Program, which shows that the cardiac unit at the Royal Infirmary of Edinburgh carried out almost twice the procedures from 2015 to 2024 as those of similar size at the Golden Jubilee and Aberdeen Royal. There is good practice in the NHS, but not everywhere. Only clinical staff can identify efficiencies, so these articles explore other areas.

The second two cover lifestyle issues that cost the NHS a fortune. The fourth deals with over-diagnosis, which Suzanne O’Sullivan (The Age of Diagnosis: Are Medical Labels Doing Us More Harm Than Good?) defines as “low-value care. It means spending money to treat people for diseases that would never have progressed and monitoring people with minor symptoms that would resolve spontaneously if left alone.”

But first, let’s consider the part that social care plays. According to Public Health Scotland, patients who were well enough to be sent home spent 666,190 days in hospital in 2023-24. About one in ten bed days were occupied by people with delayed discharges due to:

(a) additional physiotherapy or ancillary care treatment;
(b) delays in implementing the required adaptations at the patient’s destination; or
(c) delays in someone assuming responsibility for the patient upon discharge, including difficulties finding care homes or community care packages for elderly and vulnerable patients.

This article considers the last two. Improvements to social services are urgently required to prevent bed blocking and support primary care. Successive governments have failed to support this sector – quite the opposite. In May 2023, the Abbeyfield group of care homes announced that it was closing 43 properties because it couldn’t afford the mandated Energy Performance Certificate C rating by 2030. Net zero rears its costly head once again.

The NHS, with its unionised labour, obtains pay rises from a Labour government – itself funded by unions – and has seen real-terms funding increases year on year over the last twenty years, without guarantees of efficiency measures to ensure that this money is well spent. In contrast, social care staff, mostly employed by the private and third sectors, have seen real-terms pay reductions.

It makes sense to encourage more care beds and more home care, not fewer

The cost of residential care is between £1,400 and £1,600 per person per week, but the state pays £881 through the National Care Home Contract. The care home makes up the difference by charging private clients extra – perhaps £2,000. If someone is in a hospital bed because a care bed is unavailable, the lost value is £1,032 per day. It makes sense to encourage more care beds and more home care, not fewer.

People require to be assessed for care. Due to staff shortages, around 9,400 people are on waiting lists, with waiting times increasing from about six to fifteen weeks. This must be addressed. Scottish carers are registered, unlike the rest of the UK. They should not be dismissed as low-skilled workers.

Instead of targeting funds to those who need it most, the SNP spends around £25 billion per year on social security. “It is expected that Social Security Scotland will be supporting around two million adults and children, with around £5.3 billion in benefit spending this financial year”. That is about half of Scots on benefits – a statistic that helps explain why so many people vote SNP. But a dependency culture is bad for people’s self-esteem and mental health and is economically unsustainable, with too many people relying on benefits and too few contributing to wealth generation.

This is a circular problem. People on low wages need benefits because of the high cost of living – not least due to some of the highest energy costs in the Western world. Why go to work when it is more profitable to stay at home?

Scottish Care is the representative body for independent social care services in Scotland, with around 350 organisations as members. They employ 103,000 people, including 5,000 nurses. They provide 75.5 per cent of all care services, and 85.9 per cent of home services for older people. Home-based care saves millions compared to residential alternatives.

There are 25,000 staff vacancies in Scotland, with few applications from Scots. The sector used to recruit in the EU, but now targets India, the Philippines and Africa. Chief Executive Donald Macaskill says that eighty per cent of carers’ partners are also economically active, contradicting the assumption that dependents are a drain on the economy. A typical carer is on the minimum wage of £12.60 per hour, but £15-18 is needed to attract suitably capable people. Delivery drivers earn more. Yet 800,000 Scots of working age sit at home on benefits.

The Scottish Government spent £30m on studies exploring the creation of a National Social Care Service but ultimately backed away from meaningful reform, reportedly due to union pressure. Yet a spend-to-save approach – with national targeting of resources to areas of greatest need – would improve outcomes and reduce costs over time. Too often, Holyrood politicians blame local authorities for failings in social care and education when it is they who should act.

CLWs would represent good value for money

Voluntary Health Scotland represents several third-sector health organisations. It advocates increased use of community link workers (CLWs), who address the socio-economic and personal (non-medical) issues affecting patients’ health and well-being – issues which would otherwise burden far more expensive GP time. Twenty of the 27 CLW programmes are delivered by third-sector organisations, which VHS argues respond more flexibly and efficiently than state-run alternatives.

The CLW function has been described as “signposting” patients to agencies, services and places which can help them. “Social prescribing” involves individual and holistic assessment of patient needs, often involving home visits. This can alleviate social anxiety, depression, financial stress and isolation. Advice is given on issues which may be simple to resolve but appear complicated to individuals with low confidence or self-esteem. The strongest attribute of a CLW is common sense.

CLWs empower people to make changes and build confidence for self-management. In a broken society – where people live in damp, cold homes, and drug and alcohol abuse becomes a coping mechanism – a significant expansion in CLWs would represent good value for money. It would ease pressure on primary care and help more people return to work and move off benefits.

The next two articles will explore how individuals can help themselves to help NHS Scotland.