Senior leaders across NHS Scotland have issued a stark challenge to the Scottish government, claiming its plans for a National Care Service would amount to a ‘dismantling of the NHS as it currently exists’.

A joint evidence paper from Scotland’s NHS board chief executives and chairs calls for a wholesale rethink of the government’s proposals and for NHS leadership to be involved in drawing up a fresh approach.

They are concerned that the plans – which were initially aimed at reforming adult social care – entail major changes to the structure of the NHS at a time when staff are focused on recovering from the pandemic.

Worries largely relate to ministerial plans to include community health services, including GPs, in the new National Care Service.

The leaders’ response to the government blueprint for a national care service, published last week, says this would be a “backward step” and create a “fracture at another critical point in our health and care pathway”.

It is an unprecedented challenge to proposals set out by the social care minister, Kevin Stewart, who said he wanted to go beyond the recommendations of the independent review of adult social care and “create a comprehensive community health and social care service that supports people of all ages.”

But NHS leaders say there is a lack of detail on how this “radical restructuring” will affect the health service – and not enough evidence that this will improve patient care. They go on to say the consultation process and the timescale for these changes is “extremely challenging and optimistic”.

They add: “We do not believe this proposal offers a unified, optimal service model and/or best value for populations at local, regional, and national levels, notably when we commission and procure services”.

The paper was contributed to by the leaders of all 14 regional health boards and eight national boards. Boards have also made individual submissions criticising the plans. Analysis of the 1,300 consultation responses is currently underway and a report is set to be published soon.

GPs are the ‘bedrock of the NHS’

In the run-up to Christmas, Health and Social Care Secretary Humza Yousaf hinted that some of the most controversial plans to move GPs out of the NHS and into a new NCS could be ditched. Both the BMA and the Royal College of GPs are concerned the change is being rushed through.

Adding to the pressure, health service leaders say in their submission they have “significant concerns” about changing the position of general practice, which they describe as the “bedrock of the NHS”. 

In their response, the group argues all community health staff should remain within the NHS, warning transferring community services to an NCS would ‘disconnect them’ from local acute hospital services. They suggest there is little evidence for the move, stating:

“…we must assume that any proposed structural change to the NHS would be subject to a separate formal consultation…We would expect this to include a clear and unambiguous case for change, supported by evidence that sets out the rationale for change to the public”.

An alternative model

The 87-page joint submission sets out an alternative that NHS leaders believe would be a less disruptive model, calling for a “fully integrated health and social care system for each appropriate boundary”. This would see closer working between existing organisations, rather than the creation of a separate care service.

Separate submissions from NHS boards also raise concerns about how the NCS will link with the health service.

NHS Greater Glasgow & Clyde, the largest health board, said it was concerned about the ‘extremely challenging’ timescales and would prefer integration with ‘minimal structural change, with a much longer timeframe, and with proper engagement with the leadership teams’. The board questions whether ministers have considered ‘less dramatic’ changes to the existing integration model.

Another board, NHS Lanarkshire, said the ‘rationale for a nationalised service that removes responsibility from local level to the centre is not explained or justified.’

The future of IJBs

Under government plans the current Integration Joint Boards (IJBs), which are joint council-NHS governance bodies overseeing local health and social care partnerships, would get more powers and be directly funded as local delivery bodies of the National Care Service. They would be responsible for commissioning services from both the NHS and councils.

But NHS chairs and CEOs say creating a third organisation could cause “greater confusion, fragmentation, and bureaucracy…this presents significant risks for the users of health and care services”. In a separate submission, half of the current IJB chairs say the proposals as they stand would be less effective than the current model.

Health boards that cover the same area as one local authority have questioned the need for replacing the IJB partnership model with a more independent body, with Borders health board suggesting integrating health and care into one body would ‘streamline’ governance arrangements.

NHS leaders state: ‘This consultation proposes, as part of the solution to improving social care, a further restructuring of NHS services. We have alternative views for the future of the NHS that we believe would deliver on this ambition for integrated care…we reiterate our offer and commitment to fully engage with ministers and their officials in the development of legislation to support this reform agenda.”

Read more: Scotland must not rush into National Care Service; Yousaf: NCS blueprint not ‘fait accompli’; National Care Service budget ‘far too small’

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