Chapter 12 Summary and recommendations
We all know from history that major shocks – war, an economic crash or indeed a pandemic – can provide societies with an opportunity for real change. But improvements do not just follow such traumas; they come about as a result of courageous leadership, honesty with one another and a shared will to make things better. The Scottish Government has already displayed bravery, thoughtfulness and foresight by commissioning this independent review in the midst of the Covid-19 pandemic. Next, it needs to act, we hope with support for improvement from across Scottish civic and democratic society, to deliver a system of social care that takes as its central aim the realisation of every citizen's right to participate fully in society, whatever their needs for support. And that system needs to work in full partnership with other aspects of our public services, not least the NHS but not only the NHS either: housing, and justice, education and economic development are all central too.
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?
This is a real opportunity for change. Covid-19 has highlighted more than ever the critical role that social care supports can play in enabling people to live life to the full. The focus however has been on care homes, where lack of visiting, the high rate of deaths early in the pandemic and the lack of PPE for staff were all rightly highlighted in the media and in the Scottish Government's response. There has been a tendency to overlook the many people who receive care and support at home, both formal paid care and informal unpaid care from family members and loved ones.
In the forthcoming Scottish elections there is an opportunity to secure support across all political parties to a vision for the future of care in Scotland and commitments to take radical action to begin to set us on a path to achieve that vision.
This is partly about the fact that Scotland, in common with the rest of the developed world, has an ageing population. By 2036, one in four people with be over 65. Many of us will experience a period towards the end of our lives when we will need some care and support. But, as we have demonstrated in this report, this is not just about an ageing population, or caring well for older people in our society, as vital as those priorities are.
It is too easy for us to think this is about someone else. But this is about our colleagues, our friends, our families, our neighbours, and ourselves. This is about Jack who has dementia. This is about John with cerebral palsy, this is about Jade with autism, Jagdeep with motor neurone disease, Jim the veteran who has lost both legs, Jashree with multiple chronic conditions that limit her mobility, Janet who is in her 90s and too weak to move about her home unaided. Everyone one of us has a right to live a full life. This should be more than whether we can go to the toilet, wash and dress ourselves unaided, though support for these activities of daily living is vital. Everyone should be enabled to live, work and play – to enjoy full citizenship and participation. That means support to get out and about, to join in with groups and activities that we enjoy, to work or participate in adult education and training.
Scotland needs a new approach to social care to make these aspirations a practical, everyday reality across the country. We need to create a National Care Service that is based upon a new narrative, replacing crisis with prevention and wellbeing, burden with investment, competition with collaboration and variation with fairness and equity. And we need to put people at the centre of it: people who use social care supports, their families and carers, and people who work in social care services.
If not now, when? If not this way, how? And if not us – who?
Our recommendations are as follows:
A human rights based approach
1. Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded. This could be further enabled by the incorporation of human rights conventions.
2. Delivering a rights based system in practice must become consistent, intentional and evident in the everyday experience of everyone using social care support, unpaid carers and families, and people working in the social care support and social work sector.
3. People must be able to access support at the point they feel they need it, including for advice and signposting to local community-based resources and help, and for barriers to this, such as the current eligibility criteria and charging regime, to be fundamentally reformed and removed, to allow a greater emphasis on prevention and early intervention.
4. People should understand better what their rights are to social care and supports, and "duty bearers", primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
5. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process.
6. Informal, community based services and supports must be encouraged, supported and funded to respond appropriately to the needs of local citizens, including for preventative and low level support.
7. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people's heads and must enable a full exploration of all self-directed support options that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical.
8. More independent advocacy and brokerage services, including peer services, must be made available to people to ensure that their voices are heard, and to help prepare for participation in planning and organising their support.
9. When things do not work well for people and their rights have not been upheld, they must have rapid recourse to an effective complaints system and to redress.
10. Packages of care and support plans must be made more portable and supported people should not have to fight to retain support because they have moved home.
11. Carers need better, more consistent support to carry out their caring role well and to take a break from caring with regular access to quality respite provision. Carers should be given a right to respite with an amendment to the Carers Act as required, and a range of options for respite and short breaks should be developed.
12. A new National Care Service should prioritise improved information and advice for carers, and an improved complaints process. It should take a human rights based approach to the support of carers.
13. Local assessment of carers' needs must, in common with assessment of the needs of people using social care support services and supports, better involve the person themselves in planning support.
14. Carers must be represented as full partners on the Integration Joint Boards and on the Board of the National Care Service.
The case for a national care service (NCS)
15. Accountability for social care support should move from local government to Scottish Ministers, and a Minister should be appointed with specific responsibility for Social Care.
16. A National Care Service for Scotland should be established in statute along with, on an equal footing, NHS Scotland, with both bodies reporting to Scottish Ministers.
17. The National Care Service should oversee local commissioning and procurement of social care and support by reformed Integration Joint Boards, with services procured from Local Authorities and third and independent sector providers. Integration Joint Boards should manage GPs' contractual arrangements, whether independent contractors or directly employed, to ensure integration of community care and support provision, to respect and support professional interdependencies, and to remove the current confusion about where responsibility for primary care sits.
18. The National Care Service should lead on the aspects of social care improvement and support that are best managed once for Scotland, such as workforce development and improvement programmes to raise standards of care and support.
19. The National Care Service should oversee social care provision at national level for people whose needs are very complex or highly specialist and for services such as prison social care that could be better managed on a once-for-Scotland basis.
20. The National Care Service's driving focus should be improvements in the consistency, quality and equity of care and support experienced by service users, their families and carers, and improvements in the conditions of employment, training and development of the workforce.
A National Care Service for Scotland – how it should work
21. The National Care Service in close co-operation with the National Health Service should establish a simplified set of outcome measures to measure progress in health and social care support, through which to oversee delivery of social care in local systems via reformed Integration Joint Boards and national care bodies.
22. A Chief Executive should be appointed to the National Care Service, equivalent to the Chief Executive of the National Health Service and accountable to Ministers.
23. Integration Joint Boards should be reformed to take responsibility for planning, commissioning and procurement and should employ Chief Officers and other relevant staff. They should be funded directly by the Scottish Government.
24. The role of existing national care and support bodies – such as the Care Inspectorate and Scottish Social Services Council – should be revisited to ensure they are fit for purpose in a new system.
25. The National Care Service should address gaps in national provision for social care and social work in relation to workforce planning and development, data and research, IT and, as appropriate, national and regional service planning.
26. The National Care Service should manage provision of care for people whose care needs are particularly complex and specialist, and should be responsible for planning and delivery of care in custodial settings, including prisons.
A new approach to improving outcomes – closing the implementation gap, a new system for managing quality
27. A National Improvement Programme for social care, along the lines of the NHS Patient Safety Programme, should be introduced by the National Care Service, and should address the three following key areas:
- The experience and implementation of self-directed support must be improved, placing people using services' needs, rights and preferences at the heart of the decision making process.
- The safety and quality of care provided in care homes must be improved to guarantee consistent, appropriate standards of care.
- Commissioning and procurement processes must be improved in order to provide a vehicle for raising the quality of social care support and for enhancing the conditions and experience of the social care workforce.
Models of care
28.The Scottish Government should carefully consider its policies, for example on discharge arrangements for people leaving hospital, to ensure they support its long held aim of assisting people to stay in their own communities for as long as possible.
29. A national approach to improvement and innovation in social care is needed, to maximise learning opportunities and create a culture of developing, testing, discussing and sharing methods that improve outcomes. The future role of the Institute for Research and Innovation in Social Services (IRISS) and its inclusion as part of the National Care Service must be considered.
30. There must be a relentless focus on involving people who use services, their families and carers in developing new approaches at both a national and local level.
31. Investment in alternative social care support models should prioritise approaches that enable people to stay in their own homes and communities, to maintain and develop rich social connections and to exercise as much autonomy as possible in decisions about their lives. Investment in, or continuance of, models of social care support that do not meet all of these criteria should be a prompt for very careful reflection both by a National Care Service and local agencies.
Commissioning for public good
32. Commissioners should focus on establishing a system where a range of people, including people with lived experience, unpaid carers, local communities, providers and other professionals are routinely involved in the co-design and redesign, as well as the monitoring of services and supports. This system should form the basis of a collaborative, rights based and participative approach.
33. A shift from competitive to collaborative commissioning must take place and alternatives to competitive tendering developed and implemented at pace across Scotland. Commissioning and procurement decisions must focus on the person's needs, not solely be driven by budget limitations.
34. The establishment of core requirements for ethical commissioning to support the standardisation and implementation of fair work requirements and practices must be agreed and set at a national level by the new National Care Service, and delivered locally across the country.
35. To help provide impetus and support to the adoption of a collaborative and ethical approach to commissioning, the idea from CCPS of pressing pause on all current procurement should be fully explored in the context of a National Care Service, with a view to rapid, carefully planned implementation.
36. The care home sector must become an actively managed market with a revised and reformed National Care Home Contract in place, and with the Care Inspectorate taking on a market oversight role. Consideration should be given by the National Care Service to developing national contracts for other aspects of care and support. A 'new deal' must form the basis for commissioning and procuring residential care, characterised by transparency, fair work, public good, and the re-investment of public money in the Scottish economy.
37. National contracts, and other arrangements for commissioning and procurement of services, must include requirements for financial transparency on the part of providers along with requirements for the level of return that should be re-invested in the service in order to promote quality of provision and good working conditions for staff.
38. A condition of funding for social care services and supports must be that commissioning and procurement decisions are driven by national minimum quality outcome standards for all publicly funded adult social care support.
39. A decisive and progressive move away from time and task and defined services must be made at pace to commissioning based on quality and purpose of care – focused upon supporting people to achieve their outcomes, to have a good life and reach their potential, including taking part in civic life as they themselves determine.
40. Commissioning decisions should encourage the development of mutually-supportive provider networks as described above, rather than inhibiting co-operation by encouraging fruitless competition.
41. Commissioning and planning community based informal supports, including peer supports, is required to be undertaken by Integration Joint Boards and consideration of grant funding to support these is needed.
42. Rapid delivery of all of the recommendations of the Fair Work Convention, with an ambitious timetable for implementation to be set by the Scottish Government.
43. Conduct a national job evaluation exercise for work in social care, to establish a fair and equitable assessment of terms and conditions for different roles. This should take account of skills, qualifications, responsibilities and contribution.
44. Putting in place national minimum terms and conditions as a key component of new requirements for commissioning and procurement by Integration Joint Boards. Specific priority should be given to pay, travel time, sick pay arrangements, training and development, maternity leave, progression pathways, flexible pathways and pension provision. The national evaluation of terms and conditions should be undertaken to inform these minimum standards and these should be reviewed as required.
45. Establishing a national organisation for training, development, recruitment and retention for adult social care support, including a specific Social Work Agency for oversight of professional development. The current role, functions and powers of the SSSC should be reviewed and appropriate read-across embedded for shared and reciprocal learning with the NHS workforce.
46. Establishing a national forum comprised of workforce representation, employers, Integration Joint Boards and the Scottish Government to advise the National Care Service on workforce priorities and to take the lead in creating national sector level collective bargaining of terms and conditions.
47. National oversight of workforce planning for social work and social care, which respects the diversity and scale of employment arrangements while improving resilience and arrangements for mutual support should be a priority for a National Care Service.
48, The recommendations listed above should apply to Personal Assistants employed by people using Option 1 of SDS, who should be explicitly recognised as members of the workforce, as well as employees of providers in the public, third and independent sectors. This recommendation should be delivered in full partnership with the independent living movement.
49. Prioritising investment in social care as a key feature of Scotland's economic plans for recovery from the effects of the Covid-19 pandemic.
50. Careful analysis by a National Care Service, with its partners in the National Health Service, Integration Joint Boards and beyond, of opportunities to invest in preventative care rather than crisis responses, to avoid expenditure on poor outcomes such as those experienced by people who are delayed in hospital.
51. Additional investment in order to:
- expand access to support including for lower-level preventive community support;
- implement the recommendations of the Fair Work Convention;
- remove charging for non-residential social care support;
- increase the sums paid for Free Personal and Nursing Care for self-funders using care homes to the levels included in the National Care Home Contract;
- re-open the Independent Living Fund, with the threshold sum for entry to the new scheme reviewed and adjusted; and
- review financial support made available to unpaid carers and increase investment in respite.
52. Robustly factoring in demographic change in future planning for adult social care.
53. Careful consideration to options for raising new revenues to increase investment in adult social care support.