National Care Service
The case for change
The priority is to ensure national minimum standards, improve consistency, and raise the quality of services across the country. Variation in quality and access to community health and social care has been raised as a concern by those in receipt of support and care and their families. The pandemic shone a spotlight on these issues and regardless of the systems in place people made clear that they saw the Scottish Government as accountable for failings and variations.
The establishment of a National Care Service (NCS), accountable to Scottish Ministers, will ensure that we can:
- achieve consistency across the country, and drive national improvements,
- ensure strategic level integration with the NHS that promotes preventative care and reduces the need for hospital stays,
- sets clear national standards and terms and conditions for the commissioning and delivery of services; and
- vitally bring national oversight and accountability to ensure that all individuals universally have access to the services needed.
In this chapter the proposed core scope, role, and remit for a new NCS are set out. These are considered the minimum national levers needed to deliver the pace and scale of improvement needed to improve and maintain outcomes for people across Scotland in a consistent way.
How it works now
At present, local authorities have statutory responsibility for providing social care support, and Scottish Ministers, through local Health Boards, have responsibility for health care. Under the Public Bodies (Joint Working) (Scotland) Act 2014 (PBJWSA), and secondary legislation made using powers granted by that Act, local authorities and Health Boards are required to delegate certain functions (and budgets) to a local integration authority, and may delegate others. In most areas the integration authority is an Integration Joint Board (IJB) which includes members from both the local authority and local Health Board; Highland uses a Lead Authority approach, in which the Health Board takes responsibility for all adult health and social care services, and Highland Council takes responsibility for all children's services.
The integration authority then plans what care is needed in its area and directs (and provides funding to) the Health Board and the local authority to deliver it. The local authority is responsible for commissioning and directing procurement of social care support services.
The majority of adult social care is required to be delegated to the integration authority, as well as community-based healthcare, such as GPs' contracts, community nursing (general practice nursing, district nurses, community mental health and learning disability nurses, school nurses, health visitors, clinical nurse specialists, and prison health nurses), mental health services, and services provided by allied health professionals such as occupational therapists, podiatrists, and dieticians. Where there is local agreement, social care services for children and justice social work can also be delegated. While the Independent Review of Adult Social Care (IRASC) was concerned only with adult social care, it found that integration arrangements worked especially well where the widest range of functions were delegated.
The following local authority and NHS functions are required to be delegated to Integration Joint Boards (IJBs):
- The strategic planning for Accident and Emergency services provided in a hospital
- The strategic planning for inpatient hospital services relating to the following branches of medicine:
- general medicine;
- geriatric medicine;
- rehabilitation medicine;
- respiratory medicine.
- Palliative care services
- District nursing services
- Services provided by allied health professionals such as dieticians and occupational therapists
- Dental services
- Primary medical services (including out of hours)
- Some housing functions (adaptations and housing support)
- Assisted garden maintenance
- Ophthalmic services
- Pharmaceutical services
- Sexual Health Services
- Mental Health Services
- Alcohol and Drug Services
- Health improvement
- School Nursing and Health Visiting Services
- Social Care Services for adults and older people
- Carers support services
The following additional functions may be delegated by local agreement:
- Social Care Services provided to Children and Families, including:
Fostering and Adoption Services
- Homelessness Services
- Criminal Justice Services
What are the problems?
The IRASC identified that a key problem is a lack of national accountability and leadership for social care support. This has resulted in inequitable access to community health and social care provision for people, and lack of consistency of experience of support and services across the country, with people who use supports and services often referring to a "postcode lottery". While there is good practice in many places, there is no mechanism for making sure this spreads across the country.
The aim of integration was to improve people's experience of social care, and to focus on early intervention and preventative approaches, rather than only intervening when people reach a crisis. This has not worked as well as it should have done, particularly due to a lack of collaborative leadership in some areas. Financial planning is not always integrated, long-term, or focused on providing the best outcomes for people who need support. This limits the ability of integration authorities to improve the health and social care system. There is also a lack of strategic capacity and a high turnover of integration authority staff to support planning, commissioning, and delivery. Current commissioning and procurement processes are characterised by mistrust, conflict, and market forces. Procurement methodology and practices in community health and social care have increasingly driven and sometimes undermined commissioning decisions.
Relevant Independent Review of Adult Social Care Recommendations
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
Recommendation 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.
The report also suggests that a similar body should be established for NHS Scotland, and there should be a National Integration Joint Board, bringing together the NCS and NHS to agree national strategy and priorities.
What we propose
We will make Scottish Ministers accountable for social care as they are for health care within Scotland.
We will establish a National Care Service, accountable to Scottish Ministers, which will have a clear focus on positive outcomes for people and "Getting it Right for Everyone". The NCS will work in parallel and in partnership with Scotland's NHS, but independent of the NHS.
The NCS will involve the people of Scotland in the design, development and delivery of support and services from the outset and on a continual basis.
We propose that the NCS will define the strategic direction, quality standards and the framework for person-centred operational delivery of community health and social care in Scotland. It will ensure the delivery of consistent, high standards of care for everyone across Scotland.
IJBs will be reformed and will become Community Health and Social Care Boards (CHSCBs) and will be the local delivery body for the National Care Service. The National Care Service and CHSCBs will work in concert with the NHS, local authorities, and the third and independent sectors to plan, commission and deliver the support and services that the people of Scotland require.
The NCS itself will lead on aspects of community health and social care improvement and support that are best managed on a once for Scotland basis. It will also deliver community health and social care provision at a national level for people whose needs are very complex or highly specialist, and the planning and delivery of care in custodial settings, including prisons.
The NCS will be responsible for national workforce planning and development, data to support planning, commissioning and procurement, research to support improvement, digital enablement, and national and regional service planning.
The creation of a NCS does not mean that the Scottish Government would run all care homes or other services directly. There is no evidence that providing services through the public sector increases quality, in fact in community based services, quality is generally highest among third sector providers. The IRASC also identified that it would also be enormously expensive to take social care into public ownership, expenditure that could be better used working to improve care. While some services may be provided directly, we expect that the NCS and CHSCBs will continue to commission and procure services from a range of providers, as IJBs do at present.
When the outcomes of this consultation are clear, we will consider the implications and any necessary changes in structure, integration and alignment for and with the NHS, to ensure a coherent approach to national and local strategy and delivery.
Q20. Do you agree that Scottish Ministers should be accountable for the delivery of social care, through a National Care Service?
- No, current arrangements should stay in place
- No, another approach should be taken (please give details)
Q21. Are there any other services or functions the National Care Service should be responsible for, in addition to those set out in the chapter?
Q22. Are there any services or functions listed in the chapter that the National Care Service should not be responsible for?
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