Will a better care system emerge from the Covid crisis?

The appalling loss of life and challenges facing the care sector in Scotland during the Covid crisis shone a spotlight on services that for years have been buckling under enormous pressures. In September, Nicola Sturgeon announced an independent review into the future of adult social care.

"The National Health Service was born out of the tragedy of World War Two. Let us resolve that we will build out of this Covid crisis, the lasting and positive legacy of a high quality, National Care Service," the first minister told MSPs.

That review - led by former NHS Scotland boss Derek Feeley - has spoken to more than 1,000 users of social care and experts to develop a blueprint for the future. So what does it recommend and will it happen?

The review talks of a "new narrative" - a different way of looking at the issues.

Instead of seeing social care as something that responds to a "crisis", the focus should be on "prevention" - viewing care as an asset that helps people achieve their goals and maximise their wellbeing.

Rather than view the challenges as a "burden", care should be regarded as an "investment".

The existing system often feels like a "guddle" - bureaucratic and difficult to navigate with assessments and eligibility criteria adding to the stress.

Service users say the threshold for support is too high, only available when they are unwell or in crisis. There needs to be a more "holistic approach", less focused on money, aiming to achieve a wider "wellbeing".

At the core of a future system should be a "human rights approach".

One person described their experience of the current assessment system as "brutal".

Rather than focusing on eligibility and costs, the emphasis should be on enabling autonomy and participation in decision making.

It recommends that barriers such as charging for basic services or eligibility criteria be reformed or removed.

Assessment processes that make decisions "over people's heads" should be replaced by a "supportive process involving good conversations".

Singled out for praise is "self-directed support" - a system introduced in Scotland in 2013 where people with disabilities are allocated a budget to plan their own services, as equal partners with council social care staff.

"We need to hear the voices of people who need social care support. They need to be around the right tables. They need to be equal partners in this."

Where people feel their rights have not been upheld there should be an effective complaints process.

The review calls for redesign of the system to provide fairness and a national approach.

This would involve the establishment of a National Care Service which would be accountable for social care support, instead of local councils.

On the same legal footing as the NHS, this would report to Scottish ministers, and a minister of social care would be appointed.

The National Care Service would oversee the commissioning of local services by reformed Integration Joint Boards (these exist already, bringing together councils and the NHS) which would be funded by the Scottish government.

The services themselves would be provided by councils, private companies, voluntary and community organisations.

The review considered nationalising the private care sector but this is not one of the recommendations.

It concluded that nationalisation would be too expensive, time consuming and there would be no guarantee of improved standards.

But it does call for greater financial transparency from the private care sector to ensure there isn't "leakage" of funds that could be reinvested in raising standards.

"In every single meeting we've had... everybody has said if you invest in one thing, invest in the workforce."

Those who work in social care, often female support staff, believe they do vital skilled work - but they are undervalued and underpaid.

There is also a lack of training opportunities which sometimes has serious consequences for those who use the services.

The report says pay needs to improve - and notes that trades unions have called for a minimum rate of £15 per hour.

It backs the implementation of Fair Work principles to improve conditions and also wants a national training body set up.

The same sense of being "undervalued" applies to unpaid carers - thought to number 700,000 in Scotland and described as a "cornerstone" of social care support.

The review calls for better, more consistent support for unpaid carers, involvement in decision making and regular access to quality respite provision.

A key role of the National Care Service would be to set the priorities for improving services and draw up a national improvement plan.

While praising the idea of self-directed support, it says its implementation needs to be better.

Safety and quality of care provided in care homes must be improved, with guaranteed consistency.

Many of those who spoke to the review were uneasy that such a large part of the care system was run for profit.

While rejecting nationalisation, the review urges a more a more actively managed market, aimed at fulfilling a longer term strategic vision.

Private care homes would need to demonstrate that a reasonable proportion of profits were reinvested in the service.

The improvement plan would also look at ways of improving conditions for the social care workforce.

It's a big ambition - but the report points out it wouldn't be starting from scratch. Aspects of the existing social care system in Scotland are already "groundbreaking" and "worthy of celebration".

The integration of health and social care services and self-directed support are examples of a "scaffolding" on which to build a new system, it says.

But the report also notes there's often a "chasm" between what new laws promise and the actual "lived experience" of service users.

And then there's money.

The report acknowledges that achieving this vision would require considerable investment. The formal adult care system already costs £3.8bn a year, with about two thirds of it spent on services for older people.

It recommends scrapping charges for non-residential social care support such as support at home and day care - which would cost upwards of £50m a year.

Another recommendation - boosting the amount paid or Free Personal and Nursing Care in cares homes - would cost £116m a year.

Raising the Real Living Wage for all care staff to £9.50 per hour would cost £15.5m - but the more ambitious £15 rates suggested by trades unions could increase the wage bill by more than £500m.

The review backs continuing the Independent Living Fund for people with disabilities, with new thresholds and investment, at a cost of £85m annually.

But it argues that investment in social care increases Scotland's wellbeing as a nation as well as creating jobs and stimulating economic growth.

A better system could also reduce waste such as delayed hospital discharges - or "bed blocking" - that cost the NHS more than £130m a year.

How to raise the money is a matter for politicians. Options for financing listed in the report include mandatory social insurance or a new local tax.

Nicola Sturgeon described the review as a "vital first step" and promised her government would respond in "due course".

Derek Feeley acknowledges it's a tough proposition to put to voters - but argues it has to be a priority in the post-Covid future.

"People have asked us, how can we afford a National Care Service? Given the conclusions we have set out here, we would ask in response - how can Scotland not afford it, ethically or indeed economically?"