Coming Home Action Plan 2026

4. Priority Issues and Actions

This section sets out the work undertaken by the subgroups working on the seven priority issues identified by the SLWG and outlines strategic aims with key actions to achieve these. Indicative timescales for each of the actions are set within the parameters of short term (up to 6 months), medium term (6-24 months) and long term (24 months plus). Progress on actions will be reviewed on a regular basis.

Key Delivery Partners

Actions will be delivered through collaborative working between lead partners including Scottish Government, COSLA, Public Health Scotland (PHS), HSCPs, third sector bodies, Health Care Improvement Scotland (HIS) and the Peer Support Network, with input from lived experience interests.

Dynamic Support Register

Public Health Scotland publish National DSR Data quarterly. At a local level, data supports areas to proactively plan services and reduce prolonged hospital stays and out-of-area placements, and to prevent unnecessary hospital admissions for people with learning disabilities and complex needs. At the national level, the DSR enables national monitoring of progress towards achieving Coming Home.

The aim of the subgroup was to improve the quality, consistency and awareness of DSR data, and ensure that data gathered is being used effectively at local and national level to underpin action and provide visibility of progress towards achieving Coming Home.

Progress to date

To support its work, the subgroup issued a survey to local Coming Home leads in every HSCP to understand how the DSR was being used locally. The DSR is a relatively new dataset, and this is the first national insight into how it is being used locally. Responses were reviewed and discussed by the subgroup.

Overall, the survey response was positive, with key findings as follows:

• evidence that the DSR is being embedded in local practice and largely used as intended, although some areas are further along their journey towards fully embedding the DSR
• the DSR is being used effectively to reduce prolonged hospital stays and inappropriate out-of-area placements, increasing visibility, monitoring and accountability, and informing local strategic planning
• responses also highlighted barriers to progressing Coming Home, including budget pressures and the availability of suitable housing and support services

These findings suggest that the DSR is contributing towards progressing Coming Home for people with learning disabilities and complex support needs at a local level, but it is noted that the DSR is only one element of Coming Home policy and practice.

The subgroup also met with PHS to understand the data collection and reporting process and identify potential improvements, including the timing of publication.

The survey of Coming Home leads provided insight into how the DSR was being used locally and suggested that local areas were at different stages in their journeys towards fully embedding the DSR in local processes. It was agreed that subgroup members would host a seminar for Coming Home leads to share these insights and provide an opportunity for peer learning and support to contribute towards local improvement.

Discussions with PHS highlighted specific issues with data submissions, including missing data and late returns. The Scottish Government will work closely with PHS and support the development of closer liaison between Coming Home leads and PHS to address any issues with data returns. Common issues will be logged and communicated with Coming Home leads via existing networks, with updated guidance being issued if required.

It was also felt that the quality of data submissions were sometimes affected by local skills gaps, unclear roles and responsibilities, and lack of communication. Providing clarity, support and accountability on the role and skills required of local Coming Home leads and those supporting them could help address this. This is addressed under the ‘Next Steps’ section in this plan.

Changes to the content of the PHS quarterly data publication were proposed to help monitor progress towards achieving Coming Home, including the addition of the number of people admitted to hospital, and the number of people discharged from hospital during the period.

Strategic Aim 1: Continue to improve data collection and analysis through the Dynamic Support Register and ensure effective use of this data to monitor progress and support delivery of Coming Home at local and national levels.

Action 1.1 The Scottish Government will ensure effective liaison between PHS and Coming Home leads to improve the quality and timeliness of quarterly DSR data submissions, collate common issues, and produce updated guidance.

Indicative timescale - medium term

Action 1.2 The Scottish Government and PHS to agree changes to DSR quarterly publication with PHS for 2026-27. This may include reporting of additional data, publication timescales, dissemination and quality assurance processes.

Indicative timescale - medium term

National Support Panel

The National Support Panel (NSP) is essential to addressing systemic barriers that lead to prolonged hospital stays, out-of-area placements, and prevent unnecessary hospital admissions for people with learning disabilities and complex needs by planning effective supports and transitions to services. Previous work and the Coming Home Implementation Report highlight the need for a national mechanism that can provide expert guidance and support, share best practice and potentially escalate issues that local systems cannot resolve alone. Establishing the NSP will ensure Scotland has a consistent human rights-based approach to supporting people with learning disabilities and redesigning services to meet their needs.

The aim of the subgroup was to consider options for the NSP nationally, informed and shaped by the outcomes of a pilot panel, and to inform potential legislation within the LDAN Bill. The specific aim was to scope ideas for the format and function of the NSP prior to national development and implementation, including referral criteria. This involved developing practical criteria, setting up a pilot and identifying an area willing to be part of the pilot. The pilot will focus on scoping out different approaches to the NSP and testing its function. The pilot will explicitly identify and adopt human rights requirements and measure its success against those requirements. Learning from the pilot will help define the NSP’s function and format, ensuring it is practical and effective. Its impact is intended to be significant in reducing prolonged hospital stays, out-of-area placements and enabling sustainable community solutions, thereby improving outcomes for individuals and their families. It is intended that this work will help drive systemic change and ensure the Coming Home commitments are delivered across Scotland.

Progress to date

A health board area has been approached and local partners have agreed to participate in the initial pilot to test the principles, function and format of the NSP. The scope of the pilot will include people with learning disabilities who are delayed in hospital in the pilot area. The principles for operation, confidentiality and conduct of the pilot have been set out in a Terms of Reference with further development planned by the pilot group.

Membership of the pilot panel has been finalised and includes members from the Coming Home SLWG and lived experience representation. Additional members with specific expertise will be included as the need is identified.

The pilot will run for three months initially. Initial meetings have been held and work has started to map existing functions (Mental Welfare Commission, Care Inspectorate, National Care Service Advisory Board) to avoid duplication and identify gaps.

Strategic Aim 2: Consider options for the National Support Panel, informed and shaped by the outcomes of a pilot panel.

Action 2.1 Establish and complete pilot of National Support Panel.

Indicative timescale - short term

Action 2.2 Review learning from pilot and provide recommendations for national development and implementation of a National Support Panel (e.g. format, function and referral criteria).

Indicative timescale - medium term

Redesign of Learning Disability Inpatient Services

The Coming Home Implementation Report was clear that people should only be in hospital for as long as they require clinical assessment and treatment. However, we know from the DSR data that between 40% and 50% of people with learning disabilities and complex needs in hospital have been classified as a delayed discharge. This suggests that only half of the inpatient beds in learning disability assessment and treatment units are occupied by people who are there because they have a clinical need. We also know that people are sometimes admitted to hospital due to the breakdown of their community placements, rather than because of any clinical need.

This also means that some people requiring clinical assessment and treatment in learning disability inpatient settings may have to wait too long to be admitted to hospital because there are no suitable beds available. This can increase the risk of out-of-area care when this cannot be provided locally.

Inpatient beds should only be used for the intended function - the treatment of a clinical need which cannot be addressed elsewhere, such as at home. They should be seen as a last resort when there is no suitable alternative. Developing appropriate care and supported accommodation in the community is key to ensuring people are not placed inappropriately in hospital.

The aim of the subgroup was to identify the number of assessment and treatment beds across Scotland and to be clear on the role and function of these services and enable us to ensure this data was consistent with DSR data.

Progress to date

The subgroup identified the need to understand the learning disability inpatient landscape across Scotland as this data was not available from existing data sources. The group designed a template for NHS Boards to complete and return, providing details of the number of hospital wards and beds categorised as specifically being for assessment and treatment for people with learning disabilities. All NHS Boards responded to this request. The sub-group engaged with colleagues in NHS Boards to further understand their submissions where required, before undertaking detailed analysis of the data.

The data collected has provided a picture of provision across Scotland. In total, it was established that there are 112 Assessment and Treatment (A&T) inpatient beds for people with learning disabilities across Scotland (excluding forensic and ‘other’ beds), located across nine Health Boards.^[5]

This data was analysed in relation to the estimated population of people with learning disabilities in each NHS Board to understand the distribution of assessment and treatment inpatient beds across Scotland. The findings suggest that bed provision is not evenly distributed across Scotland, nor is it directly related to the size of the local population of people with learning disabilities. The group also found inconsistencies in terms of the use of ‘other beds’ as some areas have ‘bespoke’ areas or units which are neither categorised as being for the assessment and treatment of people with learning disabilities or for people who require secure forensic mental health services.

This subgroup also collaborated with the subgroup for people in hospital for more than ten years to share data and intelligence and found that many of the people who had been in hospital for very long periods did not have active discharge plans. In addition, the group noted that the number of people recorded on the DSR as being in hospital was significantly higher than the number of assessment and treatment beds across Scotland that had been reported by NHS Boards.^[6] Further work on the DSR will explore the reasons for this and improve alignment between data.

Based on the data and evidence collected, and when compared with a previous study undertaken in NHS Greater Glasgow and Clyde, the sub group observed that while some Health Boards appear to have roughly the right number of assessment and treatment beds, others may have too many. The data indicates that more than half of assessment and treatment beds in Scotland are not being used for people who require assessment and treatment and whose needs would be better met in their communities. A further observation was the use of ‘other’ or ‘bespoke arrangements’ which have been developed over the years. Although these have probably been developed with the best of intentions, they are in fact long stay institutions in themselves.

Strategic Aim 3: To ensure inpatient services are only used when an individual needs assessment and treatment, and only for as long as there is a clinical need for the person to be in hospital.

Action 3.1 Develop a national vision statement about inpatient services for people with learning disabilities and complex needs only being used when there is clear clinical need, and seek support from all NHS Boards for this vision.

Indicative timescale - medium term

Action 3.2 Integration Joint Boards to ensure their strategic plans include alternative approaches to hospital admission, including crisis support, to ensure people are not admitted to hospital due to support breakdown.

Indicative timescale - medium term

Action 3.3 NHS Boards and HSCPs to work together to ensure the effective transfer of resources from hospitals to communities and re-invest in alternatives with a long term aim of bed reduction.

Indicative timescale - long term

People in hospital for 10 years or more

The Coming Home Implementation Report was clear that people should only be in hospital for as long as they require clinical assessment and treatment. However, we know from the Dynamic Support Register data that there are still people with learning disabilities and complex needs who are delayed in hospital when they do not need to be there, sometimes for many years. This was also highlighted in the Mental Welfare Commission’s (MWC) report ‘Hospital is not Home’ which considered the circumstances of 55 people who were identified as having been in a learning disability or mental health hospital for ten years or more.

The aim of this subgroup was to achieve progress towards discharge from hospital into the community for people with learning disabilities and complex needs who have been in hospital for ten years or more by identifying solutions and pathways and sharing learning.

Progress to date

The subgroup contacted all NHS Boards in Scotland to identify where there were people with learning disabilities and complex needs who had been in hospital for 10 years or more, establish whether or not a discharge plan was in place, and which HSCP led on the case. As at October 2025, in total, there were 32 people across 8 NHS Boards and 13 HSCPs reported as being in hospital for over 10 years.^[7]

Subgroup representatives engaged with the MWC to discuss ‘Hospital is not a home’ and the MWC’s progress on phase two of this work, which involves revisiting some of the individuals identified in the previous report and engaging with families and staff. It was agreed that subgroup representatives would continue to link in with the MWC on this work to support progress towards discharge for this group. The subgroup also drew information from the in-depth lived experience engagement being undertaken by the MWC as part of the ‘Hospital is not a Home’ work.

Insights gathered from discussion with the Chief Social Work Officers’ Network identified barriers to discharging people who had been in hospital for ten years or more and suggested six key themes to be considered in terms of resourcing and supporting discharge:

• accommodation and environment
• mental health and clinical needs
• workforce and provider challenges
• funding and commissioning
• family involvement and expectations, and legal barriers
• systemic and planning issues

In December 2025 a meeting was held with NHS Boards and HSCPs with responsibility for people who have been in hospital for ten or more years to explore barriers to, and enablers and solutions for discharge. This has helped to shape future work in this area.

The work to date has provided greater insight into the barriers to discharge for this specific group and possible solutions, and data collected from NHS Boards has enabled the identification of the HSCPs who have people in this group. This data and insight will contribute towards the next stage of this work, which is developing solutions to progress discharge for people who have been in hospital for more than ten years. It is hoped that learning and solutions from this work will also help progress discharge for people who have been in hospital for less than ten years.

Strategic Aim 4: Support continued progress towards discharge from hospital into the community for people with learning disabilities and complex needs who have been in hospital for ten years or more.

Action 4.1 Work with HSCPs and the MWC to mitigate current barriers and progress discharge for all individuals with learning disabilities and complex support needs who have been delayed in hospital for ten years or more.

Indicative timescale - medium term

Housing

Access to suitable housing has been identified as an area of key importance to the Coming Home agenda. Everyone should have the right to live independently, with dignity and choice, in a place they call home. This is a human right and it is not acceptable for people with no legal basis for detention to be living in institutional settings for long periods of time.

Having the right housing in the right place, enables people to be a part of their community and live close to family and friends. Enabling people to live independently increases wellbeing and reduces the likelihood of placement breakdown and admission in hospital.

The aim of the subgroup was to consider housing in its broadest sense, ensuring that HSCPs are empowered across all types of available tenancy, to seek out and secure suitable housing options for people with learning disabilities and complex care needs. This means aligning housing more closely with the Coming Home agenda, overcoming housing barriers within the process (recognising need for safe and suitable housing) and involving housing in discussions and decisions relating to the people on the DSR.

Progress to date

Discussions within the subgroup have highlighted the importance of making the Coming Home agenda an integral part of the response to the housing emergency. The Scottish Government’s Emergency Housing Action Plan, published in September 2025, recognised that having a safe, warm and affordable place to call home is central to a life of dignity and opportunity.

We know that significant pressure remains on local authorities, partners and stakeholders to deliver housing services. Action should be built in at all levels, with strong engagement between and leadership from national and local politicians, and effective partnership working to ensure that suitable accommodation is in place locally to support people being discharged from hospital.

The subgroup held a surgery with members of the Peer Support Network to explore issues they were experiencing around housing. These included:

• the cost of adaptations and who funds them
• the lack of funding during the interim period between housing being secured and occupied
• lack of knowledge about options to pay for housing, such as benefits-based mortgages
• the potential for loss of tenancy when people are in hospital for a long period of time

To address issues raised through discussion, the subgroup has developed a Housing Options Guide. This is a practical and person-centred resource, specifically designed to support Local Authorities and HSCP leads to deliver their role within the Coming Home framework.

Housing Options Scotland (HOS) has been involved in the subgroup’s work and the Housing Options guidance was prepared by HOS staff who both have and can access a range of lived experience.

Strategic Aim 5: To ensure that people with learning disabilities and complex care needs have choice and are able to access housing options that meet their needs and rights.

Action 5.1 Launch and disseminate Housing Options Guide developed by the subgroup

Indicative timescale - short term

Action 5.2 Explore opportunities to work collaboratively at both a local and national level to embed the Coming Home agenda into national housing strategy and policy, and local planning and funding decisions.

Indicative timescale - long term

Action 5.3 Explore the establishment of a Coming Home Housing Advisory Service, in order to help address housing barriers for this group.

Indicative timescale - short term

Skilling Up and Strengthening Community Services

The Coming Home report (2018) highlighted that breakdown of community support and subsequent admission to hospital or move to out-of-area placement was frequently the result of community services experiencing difficulty in meeting the needs of people with learning disabilities and complex support needs, particularly those with behaviours that challenge.

Since then, subsequent work has shown that breakdown of community support continues to be a factor in admission to hospital. Strengthening and skilling up community services is therefore a key focus of the Coming Home agenda. This relates both to social care provider organisations and also to community integrated teams, where specialist skills and expert knowledge are needed to provide support to those with complex needs.

This subgroup’s aim was to identify, describe and highlight the skills needed to provide this type of specialist support in the community, recognising that organisational resilience and support are important factors, as well as individual knowledge and skills. Through its work, the subgroup aimed to ensure that:

• staff are provided with the training and support that they need to equip them with knowledge and skills to support those with the most complex needs to live good lives in their local communities
• services and organisations (including both care providers and community integrated teams) are better able to identify the training that staff need in order to provide successful complex needs support, and that they know where to access this training for their staff
• services and organisations have an increased awareness of the additional organisational oversight and staff support required in addition to training, for example, coaching, debriefing, learning reviews, team meetings and supervision
• those commissioning services will have a greater ability to identify the necessary attributes within support organisations which evidence their ability to provide complex needs support
• complex services are funded sufficiently in order to provide the additional training and management support that is necessary to support the Coming Home cohort

Progress to date

The subgroup developed and issued an online survey to gain views from a wide range of practitioners in the health and social care sector, as well as family carers with lived experience of having a family member with learning disabilities and complex support needs. The survey asked respondents to rate certain skills and attributes, both for individual staff and also for support organisations. Despite short timeframes, there was a good response to the survey with 137 completed surveys returned, as well as a range of additional information shared via direct contacts with group members.

In addition to the survey, a review of existing competency models, training frameworks, and good practice guidance was carried out to identify and describe the relevant skills required. This review included guidance from NHS Education Scotland NES, the Positive Behavioural Support Academy (PBSA), the National Institute for Health and Care Excellence (NICE), the British Institute of Learning Disabilities (BILD), Qualifications Scotland (QS), and others.

The findings from the survey and the review of guidance were analysed, summarised and developed into a comprehensive list of the knowledge and specialist skills that are needed by those providing support. Based on this, Coming Home Training Guidance was developed to describe the training needed by social care provider staff and community integrated teams to successfully support people to live within their local communities. This also includes the management support and organisational systems required to support complex work.

Survey respondents were also asked to identify training gaps in their areas and organisations. This informed work to map where appropriate training, learning and development information is available across Scotland with a focus on information that is freely available. This information is included in the guidance.

Previous lived experience engagement and research into what people with learning disabilities look for in their support staff has helped identify the different competencies within the Coming Home Training Guidance. This includes the importance of respecting human rights, how essential it is to learn the person’s unique communication style, the need for positive support environments and the minimal use of restrictive practices.

Strategic Aim 6: To strengthen community services and ensure staff are equipped with the knowledge and skills to support those with the most complex needs to live good lives in their local communities.

Action 6.1 Share the subgroup’s Coming Home Training Guidance across the health and social care sector for those working with people with learning disabilities, complex support needs, and behaviours that challenge, and with family carers. Develop an implementation plan to support adoption and embedding of this within HSCPs, social care providers and community teams.

Indicative timescale - medium term

Action 6.2 Develop additional training materials needed to address identified gaps (e.g. reducing use of restrictive practices) and commission a suitable provider of freely available, quality online training.

Indicative timescale - long term

Collaborative Approach to Commissioning Services

The Coming Home Implementation Report (2022) reported that improvements were required to the process for commissioning social care support, with high levels of collaboration and partnership working needed in order to develop positive community alternatives to hospital and delayed discharge and inappropriate out-of-area placements.

Commissioning services for people with complex care needs always requires a person-centred, human rights-based approach that fully involves the individual, their family, and other important people in their life throughout the process. Personalised approaches, such as self-directed support, provide a mechanism to ensure people have choice and control in how their social care support is provided, and should be the main route to plan and deliver individual community-based solutions for people on the DSR.

The aim of this subgroup’s work was to complement this approach by identifying opportunities for public bodies and partners to work together, regionally or nationally, to develop and secure community-based supports that are currently limited or unavailable. The subgroup used the term ‘collaborative commissioning’ to describe this process. By pooling expertise and resources, collaborative commissioning can create a stronger foundation of options, enabling more effective personalised planning. The subgroup focused on the structures, resources and investment required for effective commissioning, and on further work to explore collaborative opportunities.

HIS, the Institute for Research and Innovation in Social Services (IRISS) and the Coalition of Care and Support Providers Scotland (CCPS) have published research on ethical and collaborative commissioning, sharing examples of Public Social Partnerships, alliancing, community commissioning and partnership working within different HSCPs. However, there is yet to be a focus on how collaborative commissioning might better support the Coming Home agenda.

Progress to date

Using the DSR data, the subgroup identified geographic clusters where common needs would enable opportunities for joint working and collaboration. Commissioners from those clusters joined exploratory discussions, which provided rich information about the potential barriers to collaborative commissioning, and also on the progress being made with commissioning support for individuals currently on the DSR (in one area the number of delayed discharges had reduced from 18 to 7, with 4 of those delayed now having solid plans for discharge). Key reasons for delays included issues with housing, legislation, capacity of teams, the nature of procurement. Particular issues with cross-boundary working and ordinary residence were also identified.

Preventing admissions is a key factor in reducing fluctuations in the delayed discharge category, which led the subgroup to consider the potential for collaborative commissioning around future need to prevent admission to hospital for younger people (many of whom are currently on the DSR as being at risk of support breakdown). We heard about examples where collaboration across local areas was being explored and the challenges, including the complexity of the risks that would need to be held by the host authority, the differing views of local authority legal teams and the funding and resourcing for this sort of approach.

In collaboration with HIS, a mapping exercise is being developed to establish existing routes to engage with services. Recurring themes included funding and resourcing of support, the cost of commissioning individual support arrangements and the need for bridging finance. The subgroup engaged with the Independent Living Fund Scotland (ILFS) to explore options for the ILFS to provide extra financial support to people in the Coming Home population, to support their choice to live independently in their homes and in their local communities. While the group recognised the challenges of this option (managing funding from multiple sources, application complexity, relatively low maximum award currently in place, funding not for assessed need) there was an interest in considering any option which would enable local funding to be topped up.

The subgroup also considered the range of additional costs that are required to sustain complex support arrangements including additional management time for mentoring and support, as well as comprehensive training and capacity for team meetings and briefings.

There was acknowledgement of the issue around integrated working with the NHS, whereby public bodies could better work together to make better use of their combined resources (including challenges relating to resource transfer) and out-of-area spend which can be reinvested to meet an individual's needs more locally.

Strategic Aim 7: To identify opportunities for collaborative commissioning to develop appropriate community-based support.

Action 7.1 Develop a report for Scottish Government and COSLA outlining the barriers to collaborative commissioning and make recommendations on the structures, processes and resources required.

Indicative timescale - medium term

Action 7.2 Collaborate with the Scottish Human Rights Commission (SHRC) to define appropriate and inappropriate support solutions for people who have learning disabilities and complex needs.

Indicative timescale - medium term

Action 7.3 Scottish Government and COSLA to further consider proposals for a national top-up scheme designed specifically for the Coming Home population, including potential for ILFS to have a role in supporting.

Indicative timescale - medium term