The Scottish Government undertook a public consultation on its proposals for a National Care Service (NCS) to achieve changes to the system of community health and social care in Scotland. The purpose of these proposals is to ensure that it: consistently delivers high quality care and support to every single person who needs them across Scotland, including better support for unpaid carers; and that care workers are respected and valued. The consultation is a key step towards shaping primary legislation to the Scottish Parliament to achieve these changes. These proposed reforms represent one of the most significant pieces of public service reform to be proposed by the Scottish Government.
The respondents and the responses
Overall, responses were received from 1,291 respondents. Two thirds of responses (67%) were made through the Citizen Space portal (862) and 500 were submitted by email or post. Of the email and postal responses, 407 were from organisations and 80 were from individuals (including responses in the Easy Read format). The total number of organisation email responses includes 71 written responses that were provided in addition to a consultation form response, these have been considered as one respondent for the purposes of tallying the overall total of 1,291. It was also clear from some organisational responses that they had undertaken surveys or other engagement activities in order to respond to the consultation, and were therefore representing the views of a number of people.
Comments on the consultation process
The consultation process itself attracted a substantial number of comments (please see page 19 of this report for details) and the analysis of responses should be considered in light of these comments. In summary, many respondents highlighted issues such as the length of the consultation questionnaire, the relatively short space of time in which they could prepare a response; the lack of detail around the proposals; and the nature of some of the questions which were thought to lead the respondent to a particular answer. These factors have potentially impacted on the depth of analysis that can be conducted (please see Chapter 2 for more details on the limits on the analysis). This report should therefore be read alongside the full published written submissions if further detail is required.
Overview of findings
A summary of the main findings of this consultation analysis is provided under the headings below, following the structure of the consultation document. Please note that not all respondents answered all consultation questions so the percentage values provided below should be interpreted within the overall number of responses per question provided in each chapter.
Improving care for people
Benefits of the NCS taking responsibility for improvement across community health and care services
A majority of respondents (both individuals and organisations) thought that the main benefit of a National Care Service taking responsibility for improvement across community health and care services would be more consistent outcomes for people accessing care and support across Scotland (77%). This was followed by better coordination of work across different improvement organisations (72%). Respondents tended to welcome the opportunity to create greater consistency across Scotland and to offer more guidance for people accessing care and support and staff.
Risks from the National Care Service taking responsibility for improvement across community health and care services
Risks identified included: the potential loss of the voices of people accessing care and support and care workers; the impact on local services; the loss of an understanding of local needs and local accountability; the variation of needs across Scotland especially where more rural and remote areas such as the Islands are concerned; and staffing concerns with regards to retention and morale. Other areas of concern were around the potential for increased bureaucracy and disruption to those areas that currently work well as the changes are implemented. Both individuals and organisations highlighted the potential bureaucracy and loss of localism as key risks. It should be noted that many of the comments in this section related to the general proposals for the development of the NCS rather than the specific improvement aspects of the proposals.
Access to care and support
Responses to each element of the question on access to care and support ranged from 627 to 647 (which routes respondents would use to access care and support).Speaking to a GP or another health professional (78%), and a national helpline (61%) or national website or online form (58%) were the options that were most likely to be used. Speaking to another public sector organisation or a drop in centre were the least popular options. The majority of respondents thought that a lead professional to coordinate care and support would be appropriate at an individual level.
Respondents were almost unanimous that they or their friends, families or carers should be involved in their support planning. There was also a majority in agreement with the statement that "decisions about the support I get should be focused on the outcomes I want to achieve to live a full life" (95%). Respondents also expressed strong support for a single plan under the Getting It Right For Everyone National Practice modelalongside an integrated social care and health record. It was thought by many that these measures would streamline processes and make the system easier to navigate.
Right to breaks from caring
Around two thirds of respondents thought that there should be a universal right to a break from caring. A majority of individuals and organisations (81% of all respondents to this question) valued personalised support over a more standardised support package. Around half thought that flexibility and responsiveness were more important than certainty of entitlement.
Using data to support care
A large majority of respondents agreed that there should be an integrated and accessible social care and health care record (86%) and that information about an individual's health and care needs should be shared across the services that support them (86%). There was support for legislation to ensure that care services and other parties provide information in line with common data standards. Concerns were raised by some in relation to data security and GDPR, cybersecurity; and the implementation risks of large national IT systems.
Complaints and putting things right
There was relatively high support for a charter of rights and responsibilities and agreement that there should be a Commissioner for social care. It was thought that a Commissioner would give people accessing care and support a voice and provide assurance that complaints would be addressed properly. Concerns related to fears of an additional layer of bureaucracy and to structural issues such as independence.
Residential care charges
Opinion also tended to lean towards the view that residents in care homes should make some contribution to the costs, particularly in terms of food and rent, however there was less agreement that care home upkeep should be something for which contributions should be expected, such as cleaning, food preparation, transport, maintenance, furnishings and equipment. There was also a majority view amongst both individuals and organisations that the current means testing arrangements should be revised.
A National Care Service
Overall, 477 of the 660 people (72%) that responded to this question agreed that Scottish Ministers should be accountable for the delivery of social care through a National Care Service. The main themes emerging from the responses to this question related to: the need to avoid adding additional bureaucracy; maintaining local accountability; the role of local authorities; and the challenges faced by rural and remote areas, including the Islands.
A range of other services were suggested for potential inclusion in a NCS, including aspects of housing, education and transport. There were mixed views on whether social care in prisons or children's services should be included in the open-ended responses to this question, but a majority (over 70%) were in agreement when this question was addressed explicitly and quantitatively in the relevant section of the consultation (please see below).
Other cross-cutting themes which emerged included:
- The need for more detail on the proposals to inform the debate
- The need for more detail about the costs of designing and implementing an NCS
- Transition risks and centralisation
- The impact on local authority workforces
- Localism and local accountability
- The needs of remote and rural areas
- Human rights and equality issues
- The extent of the proposed NCS
- The delivery of services under the NCS
Each of these themes are considered in more detail in Chapter 2.
Scope of the National Care Service
This section of the report considers respondents' views on the services that should fall under the remit of a National Care Service.
Overall, the majority of respondents agreed that Children's Services should be included in a National Care Service (NCS). Three quarters of individuals who responded to this question and a similar proportion of organisations were in agreement. A number of key stakeholders however did express concerns about the proposals with several suggesting that more evidence on the likely benefits of the proposals is required. There were a number of risks identified here by individuals and organisations, including the potential loss of a local dimension to responding to need and the potential loss of the link to education.
Around 70% agreed that the proposed NCS and the Community Health and Social Care Boards (CHSCBs) should commission, procure and manage community health care services. The main reasons given in support of the proposals related to a more streamlined and consistent service and improved accessibility for people accessing care and support. Reasons given by those who disagreed with the proposals included the availability of funding and perceptions of the existing relationships between health and social care.
The most frequently cited benefit of CHSCBs managing GPs' contractual arrangements was "better integration of health and social care". Nearly three quarters (74%) of individuals and six in ten organisations (61%) selected this response. This was followed by "improved multidisciplinary team working", selected by 69% of individuals and 56% of organisations. The most frequently cited risk was "unclear leadership and accountability requirements", selected by 58% of individuals and 63% of organisations. This was followed by "fragmentation of health services", selected by 47% of individuals and 56% of organisations.
Social Work and Social Care
The most frequently cited benefit of social work planning, assessment, commissioning and accountability being located within the NCS, was "more consistent delivery of services". This was followed by "better outcomes for people accessing care and support and their families". Risks identified included a loss of local understanding, the potential loss of accountability, and the risk that social work would be overshadowed by other services.
A majority agreed with the proposed leadership role of Executive Nurse Directors and that the NCS should have responsibility for overseeing and ensuring consistency of access to education and the professional development of social care nursing staff, standards of care and governance of nursing, with almost two thirds in agreement. There was also strong agreement with the proposal that Executive Nurse Directors should have a role in the proposed Community Health and Social Care Boards.
Justice Social Work
Nearly two thirds agreed that Justice Social Work should be included within the remit of the NCS (62%). Reasons given included the need to keep all forms of social work together and the fact that offending behaviour is often linked to other care needs. Those who disagreed tended to say that the proposed NCS is too large and centralised and that there is a need to reflect local requirements. The main benefit was thought to be "more consistent delivery of justice social work services". Around half of respondents to the question on risks selected: less efficient use of resources; worse outcomes for people accessing care and support; poorer delivery of services; and weaker leadership of justice social work.
A majority of respondents (72%) also agreed that responsibility for social care services in prisons should be given to a National Care Service. Reasons given included better support for prisoners with mental health problems or learning disabilities and smoother transitions at the point of release, amongst others.
Alcohol and Drug Services
A majority also agreed that Alcohol and Drug Partnerships would have the benefits of providing greater coordination of Alcohol and Drug Services (81%) and better outcomes for people accessing care and support (75%). Confused leadership and accountability was viewed as the main drawback of the Partnerships. Three quarters agreed that they should be integrated into the CHSCBs. Eight in ten agreed that residential rehabilitation services could be better delivered through national commissioning.
Mental Health Services
Around three quarters of respondents agreed that the list of mental health services provided in the consultation document should be incorporated into a NCS. In response to the question on how best to link the mental health care elements into a NCS, suggestions included: quicker referrals; the use of multi-disciplinary teams; and better sharing of information across services.
National Social Work Agency
There was a general agreement around the potential benefits of a National Social Work Agency that were outlined in the consultation document: improving training and continuous professional development; supporting workforce planning; and raising the status of social work. Two thirds agreed that the proposed Agency should be part of a NCS (66%). Around 80% thought the Agency should have a leadership role in relation to social work improvement, social work education; and a national framework for training and development.
Reformed Integration Joint Boards: Community Health and Social Care Boards
This section of the report considers the responses to the proposals to reform the existing Integration Joint Boards (IJBs) into Community Health and Social Care Boards (CHSCBs).
Around three quarters agreed that Community Health and Social Care Boards (CHSCB) should be the sole model for local delivery of community health and social care in Scotland, with individuals (77%) and organisations (73%) broadly similar in terms of levels of agreement.
Benefits mentioned included greater standardisation across Scotland, as well as helping to improve equality of access to services, although some were concerned about the potential lack of local decision making and that a "one size fits all" approach would not work. The majority of respondents also agreed that CHSCBs should also be aligned to Local Authority boundaries (81%).
Membership of Community Health and Social Care Boards
A range of roles were suggested as potential members of the Boards, including people with lived experience and frontline workers. There was a view that their involvement should be meaningful and that these members should not be included in a tokenistic way. In line with this, there was a strong majority in support of the proposal that all Board members should have voting rights with 90% of individuals and 86% of organisations that answered this question in agreement.
Community Health and Social Care Boards as employers
A large proportion (78%) agreed that the Boards should employ Chief Officers and their strategic planning staff directly. Other comments in relation to this question referenced the need to avoid unnecessary bureaucracy and for strong leadership.
Commissioning of services
This section of the consultation addressed the ways in which the National Care Service can embed ethical principles at a local level to deliver support and solutions for better consistency of access, drive up quality and secure person-centredness.
Structure of Standards and Processes
A majority of respondents (83%) thought that an NCS should be responsible for developing a Structure of Standards and Processes. A similar proportion agreed that a Structure of Standards and Processes will help to provide services that support people to meet their individual outcomes. Some thought that local as well as national considerations should be taken into account.
Market research and analysis
A smaller proportion, but still a majority (63%), agreed that an NCS should be responsible for market research and analysis. Comments here related to the need for independent research and consideration of local circumstances.
National commissioning and procurement processes
A majority also agreed (76%) that there will be direct benefits in moving the complex and specialist services as set out to national contracts managed by the NCS. Comments here relate to: the fact that the current system is perceived as disjointed; people should get the same help wherever they are; and the need to maintain an understanding of local needs.
This section considered the regulation of services under the proposed NCS. It addressed: the core principles for regulation and scrutiny; strengthening regulation and scrutiny of care services; a market oversight function; and enhanced powers for regulating care workers.
Core principles for regulation and scrutiny
There was a general agreement with the 10 Principles proposed for regulation and scrutiny. Several respondents noted that care should be taken not to overburden providers with too much regulation or scrutiny and that regulation should be proportionate. The Scottish Human Rights Commission and the Equality and Human Rights Commission suggested that there should be explicit reference to human rights legislation in the Principles. Overall comments related to the need for the Principles to be clear and in Plain English and to reflect the views of people with lived experience.
Strengthening regulation and scrutiny
There was also strong support for the proposals outlined for additional powers for the regulator in respect of condition notices, improvement notices and cancellation of social care services, with 88% of respondents to this question in agreement. Other comments in regard to the powers of the regulator included the ability to disbar providers on the grounds of poor performance and more unannounced visits.
Market oversight function
There was also strong support for the regulator having a market oversight function with 84% of individuals and 87% of organisations who responded to this question in agreement. Around nine in ten thought that this function should apply to all providers, not just large providers.
There was support for the proposal that the regulator should have formal enforcement powers which enable them to inspect care providers as a whole as well as specific social care services, with again nine in ten in agreement.
A large majority of respondents agreed that the regulator's role would be improved by strengthening the codes of practice to compel employers to adhere, and to implement sanctions resulting from fitness to practise hearings.
There was a view that all workers in the care sector should be regulated, with Social Work Assistants and Personal Assistants mentioned in particular.
Valuing people who work in social care
This section of the report considers the responses to proposals for a 'Fair Work Accreditation Scheme', the development of an integrated workforce planning system and the establishment of a national organisation for training and development within social care. The role of personal assistants and the support available to them are also addressed.
There was strong support for the concept of the Fair Work Accreditation Scheme amongst individuals and organisations alike. Overall 83% were in favour. There was a view that such a scheme would help underscore the value and importance of people who work in social care.
Improved pay and conditions for people working in the care sector were also supported, with 83% of respondents ranking improved pay and 79% ranking improved terms and conditions (improvements to sick pay, annual leave, maternity/paternity pay, pensions, and development/ learning time) as factors that would make social care workers feel more valued in their role. Some respondents highlighted issues such as the need for parity of pay and terms and conditions across all sectors, including the private and third sectors, and between the NCS and NHS, and the need for more investment in the workforce as a whole.
The majority of respondents (87%) were in agreement that a national forum should be established to advise the NCS on workforce priorities, terms and conditions and collective bargaining which would include workforce representation, employers and Community Health and Social Care Boards. It was suggested that a national forum would be an opportunity to give employees a voice and would make the sector more attractive to recruits and increase engagement of staff.
Individuals and organisations alike were in agreement that having 'a national approach to workforce planning' (74% of individuals and 77% of organisations) as well as 'providing skills development' opportunities for relevant staff in social care (65% of individuals and 77% of organisations) would be the easiest way in which to plan for workforce across the social care sector.
Training and development
The majority of respondents agreed that the NCS should set training and development requirements for the social care workforce. There was also support for a national approach to workforce planning with three quarters in agreement.
The majority of respondents agreed that all Personal Assistants should be required to register centrally in the future. There was also widespread agreement that national minimum employment standards for the personal assistant employer and promotion of the profession of social care personal assistants would be useful for personal assistants and their prospective employers (with 81% and 72% respectively of respondents to this question selecting these options).
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