We’ve seen record investment in Scotland’s NHS. But ever-increasing numbers of people remain in hospital despite being clinically fit for discharge. Andrew Thomson, Deputy Chief Executive of social care and community development charity Carr Gomm, explores how a whole-system solution is needed if Scotland is to support more people to live their best lives in their own home. This article was recently published in the British Journal of Hospital Medicine.
In the United States, “defund the police” is a movement that supports removing funds from the police service and reinvesting in alternative forms of public safety and community support. Activists who use the phrase may have varying intentions, but at its heart, their argument is that investing in community programmes provides a better crime deterrent for communities leading to better outcomes for people and families.
Could Scotland apply the same logic to public services, like the National Health Service?
The NHS employs approximately 160,000 staff to provide primary and secondary healthcare to Scotland’s six million inhabitants.
Could we invest Scotland’s £13 billion public healthcare budget differently?
Should we defund the NHS to improve people’s lives?
State Captivity Statistics
In the year ending 31 March 2023, over 660,000 days were spent in hospitals in Scotland by people whose discharge was delayed (Public Health Scotland, 2023), at an estimated cost of £200 million.
The language of “delayed discharge” centres the problem in hospital beds, and we are encouraged to believe that even greater investment in the health service is the only solution. We must change the language to change behaviours and attitudes, to change how we consider the problem and invest in solutions.
Rather than publishing delayed discharge statistics, perhaps we should insist the Scottish Government publishes our state captivity statistics: the number of days people have been systematically held captive by the state in hospital without clinical reason.
This might shift the narrative from hospital beds and increased NHS funding, to focus instead on our social care system; a system that is deliberately designed to delay discharge and create overwhelming pressure in hospitals by not paying workers enough and having no resource capacity to support people at home.
Social Care providers do not pay their workers enough
Social care practitioners are undoubtedly underpaid for their level of responsibility in providing essential public services. These professionals are registered with a professional body and require specialist qualifications, just like doctors, nurses or police officers. Practitioners often work alone; undertaking constant risk assessments; and supporting the most vulnerable people in our communities.
The minimum wage payable to social care practitioners is set by the Scottish Government and is currently £12 per hour. Social care employers are funded, via statutory contracts administered by local authorities, on the presumption of paying this – and only this – wage. This means that the minimum wage also becomes the maximum wage because no employer is funded to pay anything else. The social care system sets and enforces an insufficient wage.
In addition, the social care workforce is a mix between those employed by a provider organisation and those employed directly by a local authority. Despite undertaking equal work, the pay and benefits of those employed directly by the state is up to 55% higher than those working for organisations funded by state contracts. (Community Integrated Care, 2024).
Social care workers are not valued equally.
The system is designed to have no resource capacity
Whilst higher wages would help employers recruit and retain more social care practitioners, this will not eradicate the issue of people’s discharge being delayed.
Let’s imagine that Mrs Smith is clinically fit to leave hospital and a social care assessment concludes that she needs routine support to help her live safely and well at home.
A social care resource is now required at short notice, generally within 24 hours, to support Mrs Smith home. But safely recruiting and comprehensively training a new worker takes several weeks. There is a mismatch in timescales.
To address this mismatch in timescales, the social care system should pay for social care providers to have a workforce capacity to be ready to support people like Mrs Smith. But it does not. The social care system does not pay for any workforce capacity.
In effect, local authority procurement fundamentalism has created a so-called “best value” contracts’ trap, and throughout Scotland we now experience social care as a zero-hours gig economy that guarantees that people are stuck in hospital every day, without the support available to get home.
Solutions are possible
The social care sector is often described as being in crisis. But every day, outstanding practitioners, working for excellent provider organisations, like Carr Gomm, support people to live their best life. Sadly, this is despite the failing social care system. Not because of it.
The social care system must change.
It must change from being reactive and crisis-led, to being proactive and preventative. It must change to value people, rather than retain its obsession with “best value” procurement.
Proactively buying workforce capacity prevents hospital admissions and hastens hospital discharge. Proactively undertaking falls risk assessments and supporting people to move more improves mobility, reduces the risk of falling, leads to improved lives, and reduces A&E admissions. Proactively listening to what really matters to people impacted by isolation and loneliness leads to people feeling more connected to, and supported by, their community.
Our social care system does not consider any of these choices to represent “best value” and so decision makers choose not to invest in them. The narrative we hear every day is that there is no spare money to invest in anything other than crisis care.
But Carr Gomm does this. We work with falls specialists to enable people to live well at home for longer; we work in communities to develop meaningful connections; and we work with physiotherapists and health coaches to support people to move more. We do this because people tell us that it matters and because people should be supported to live their best lives in their own homes, in their communities. Carr Gomm must fundraise to provide these services, because the state does not consider this value for money, and besides, there is no spare money.
The defund the police movement in the United States provokes a discussion about how to invest scarce resources to achieve better outcomes.
Should we defund the NHS? This is the wrong question.
The real question is how should we invest our scarce resources so that people can live their best lives? We surely have a right to expect our country’s systems to work for us and not against us.
After all, this is fundamentally about how we value people. These decisions affect you and me. These decisions affect our families, friends and neighbours. Is there anything more important?
Read more about how we are engaging in public conversations and policy on our Influencing Change page.
