Adult social care: independent review
The Independent Review of Adult Social Care in Scotland was led by Derek Feeley, a former Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland. Mr Feeley was supported by an Advisory Panel comprising Scottish and International experts.
Chapter 2 The purpose of social care
"Social Care should be a springboard not a safety net.”
Looking back at the history of failed adult social care reforms, the debate has all too often started and ended with funding. We have tried not to make the same mistakes. We will talk about funding in this report but only once we have described our statement of purpose for social care support in Scotland, our design of a system to deliver on that vision, and the values and relationships that will be required to make improvement happen.
There have been multiple helpful attempts to articulate a shared vision or ambition for social care.
We suggest the following as a definition:
Everyone in Scotland will get the social care support they need to live their lives as they choose and to be active citizens. We will all work together to promote and ensure human rights, wellbeing, independent living and equity.
We have been absolutely determined to describe the purpose from the point of view of people who receive or may benefit from social care support. That is why we have drawn heavily from previous articulations of vision and ambition. And, of course, the incredible input that we received as we conducted our engagement meetings has also been vital here. We have also used the term social care support throughout the report to reinforce that the person directs the system to support them – not the other way around.
Why start with purpose? To improve social care support, we must change systems and processes, but first we must change hearts and minds. A common purpose unites and helps to ensure that the right things are done well. It is the basis of continuous improvement in any system. It is difficult to conceive of a successful national scale improvement effort that did not have a unifying purpose.
In addition, the purpose needs to drive a set of changes that will lead to people being able to live their lives to their full potential. We might see those changes as follows:
- A new narrative for social care support;
- A redesign of the system of social care support (including the creation of a National Care Service);
- Redefining quality and closing the gap between intent and lived experience (the implementation gap);
- Protecting, promoting and ensuring human rights and equality;
- Greater empowerment of people who need support and unpaid carers at the level of the individual and the collective; and
- Valuing of the social care support workforce.
Giving effect to any stated purpose of social care support requires us to create the right conditions for change. When we examine successful improvement efforts at large scale, the purpose is 'hard-wired' into the design of the delivery system. The purpose needs to provide a direction for the securing of long-term results. It needs to guide our shared understanding of rights and needs. It needs to inform the planning and stewardship of resources in the system, and it needs to influence culture, behaviours and values.
A new narrative for social care support
Frederick Seebohm, in his landmark 1968 report, said that social care should enable 'the greatest possible number of individuals to act reciprocally, giving and receiving service for the well-being of the whole community'. Social care support is the means to an end, not an end in itself. The end is human rights, wellbeing, independent living and equity, as well as people in communities and society who care for each other. However, more recently the default narrative about social care support is too often one of crisis, unsustainability, providing for the vulnerable, staff shortages and underfunding and occasionally even harm. It's time to change that.
In our engagement sessions, there was a debate about independent living as an outcome. Independent living means people of all ages having the same freedom, choice, dignity and control as other citizens at home, at work, and in the community. It does not mean living by yourself, or fending for yourself. It means having rights to practical assistance and support to participate in society and live a full life. This is the definition of independent living adopted over many years in the strategic approach to independent living, by the Scottish Government, COSLA, the NHS and the Disabled People's Independent Living Movement.
Giving effect to the narrative requires some shifts in mindset. First, we need to shift from seeing the funding of social care support as a burden to be borne to seeing it as an investment in society and the economy. Second, we need a shift away from crisis being the entry point to the system of social care support to a system that values prevention and early intervention. Third, we need to see people who need some support for their assets, their experience, and their potential rather than as passive recipients of a service.
We will set out elsewhere in this report the strong economic case for investing in social care support. It is a good investment of public funds. It is also the right thing to do. In setting out Scotland's purpose in the National Performance Framework, the Scottish Government sets out five tests, to:
- Create a more successful country;
- Give opportunities to all people living in Scotland;
- Increase the wellbeing of people living in Scotland;
- Create sustainable and inclusive growth; and
- Reduce inequalities and give equal importance to economic, environmental and social progress.
Investing in social care support helps us to achieve every one of these.
Redesigning the system
There is a maxim in improvement science that 'every system is perfectly designed to get the results it gets'. The real point being made is that if you want different results, you need a different system. There are some good things upon which to build the new system. For example, if we did not have self-directed support, we would need to introduce it. If we did not have integration of health and social care, we would need to create it. However, to fully meet the needs, rights and preferences of people, we need some re-design too.
Further details about the proposed new system are in Chapter 6. In summary, the key design principles that have guided our thinking are not dissimilar to those first set out in the work of the Christie Commission back in 2011. The Commission set out four pillars of public service reform that should be kept in mind when developing plans for public services:
- A decisive shift towards prevention;
- Greater integration of public services at a local level driven by better partnerships, collaboration and effective local delivery;
- Greater investment in the people who deliver services through enhanced workforce development and effective leadership; and
- A sharp focus on improving performance through greater transparency, innovation and use of digital technology.
To the Christie principles, we would add:
- A stronger voice for the person requiring support and their advocates;
- A means to learn and improve across the country;
- A sharp focus on equity, equalities and human rights;
- Fairness and consistency in relation to access, eligibility and outcomes; and
- Transparency and accountability.
In order to ensure that prevention, investment in people, learning, fairness and accountability are driven by national strategy and national partnership, we need a National Care Service. To get different results, we need a different system.
Quality and the Implementation Gap
This is one of the immediate priorities for any National Care Service. At present we have no national infrastructure and no national approach for delivering on the good intent of world leading policies such as those relating to self-directed support. In this report, we have identified three areas where we can begin to create the capacity and capability required for social care support in Scotland to make breakthroughs in performance.
In order to make progress, we will need to be clear about our improvement aims, we will need to build the collective will to improve, and we will need to engage people with lived experience in generating ideas for change.
Throughout the report, we stress the importance of partnership and collaboration, and of amplifying the voice of staff and of people who need social care support. That is true at every level and in every part of the system.
At the individual level, self-directed support must be scaled-up to achieve its full potential across social care support, including at transition points from children's services.
At the population level, Integration Joint Boards and locality planners need to do a better job of building the user voice into their considerations. People with lived experience must be partners in the commissioning process and integral to decision-making and prioritisation, monitoring progress and making improvements; nothing about me, without me, as the saying goes.
And at the system level, we strongly recommend the involvement of people with lived experience in the governance of the National Care Service, including positions on the Board (see Chapter 6). We also recommend that unpaid carers should be similarly recognised. They already have a non-voting seat around the Integration Joint Board table, but they should be full partners and also involved at the Board level of the National Care Service.
"Understanding of the role of social care starts from its visibility within an integrated health and social care landscape, including ensuring the social care voice is present and heard within IJBs.”
Valuing the workforce
A welcome thread throughout our work has been unanimous support for the idea that a top priority for investment is the social care workforce. People who access social care support, advocacy groups, disabled persons organisations, and trade unions have all put forward compelling arguments for a national approach to workforce issues and for social care staff to be fully (and more generously) recognised and rewarded for the vital work they do. We make some recommendations in Chapter 10 about how this might be done, building on the strong foundations of the Fair Work Convention.
A Human Rights based approach
We believe we cannot improve social care support and people's health and wellbeing if we do not ensure their human rights are upheld. A human rights based approach has been central to the creation of the report and we believe that it needs to be central to its implementation. We set out proposals for strengthening the ability of individuals to vocalise and secure their rights in Chapter 3. We outline areas where duty bearers – organisations and professionals – need to enhance their capability to recognise and enable the fulfilment of human rights.
Human rights are described extensively in international law. Important examples for this review include freedom from torture and inhumane or degrading treatment, the right to liberty and security, and respect for your private and family life. We recognise that not all rights are absolute, that they can be overruled in certain circumstances, and that practitioners are frequently required to balance competing rights.
We are aware of work underway to consider the incorporation of human rights conventions within Scots law. Whilst we do not wish to anticipate the outcome of that expert analysis, everything we have heard during our discussions suggests that there would be a warm welcome for any approach that brought clarity and certainty to the importance of human rights, not just for social care support but across civic life. We have no doubt that the incorporation of human rights conventions would aid the direction of travel set out in this report.
We also recognise that the Taskforce for Human Rights Leadership is considering options for resolution and redress where required. Without anticipating the specific recommendations of the Taskforce on this, we welcome the attention being paid to this critical topic and agree that progress is a key priority.
A new social covenant
One key factor in the realisation of the above is the need for mutual commitment by citizens, representative bodies, providers, civic Scotland, and national government to set aside self-interest and each work together for the common good. Trust is not currently in plentiful supply in social care support and so we believe that there is a need for an explicit social covenant to which all parties would sign up. This will be particularly important if we want to achieve our aspiration for everyone in Scotland to get the social care support they need to live their lives as they choose and to be active citizens.
In their 2014 report, the World Economic Forum describes a social covenant as a vehicle for giving effect to a common set of values and beliefs:
- The dignity of the human person, whatever their race, gender, background or beliefs;
- The importance of a common good that transcends individual interests; and
- The need for stewardship – a concern not just for ourselves but for posterity.
Together, these offer a powerful, unifying ideal: valued individuals, committed to one another, and respectful of future generations. Fostering these values, which we believe would serve Scotland well as guiding principles for improving social care support, is both a personal and a collective challenge. We must do more than just talk about them; we must bring them into public life and use them to guide decision-making.
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