Review of care service definitions: challenges and recommendations

4. Challenges

This section outlines key themes from across the interview data focused on the challenges presented by the current definitions and the impact of these on a range of issues including service provision, the workforce and people accessing support.

4.1 Challenges to service provision

Restricting service provision and challenges to commissioning

Stakeholders described how the current care services definitions restricted service provision, citing challenges around having to 'fit into what was allowed within a service' and extensive bureaucratic operational processes for registration, reporting and regulation. Boundaries and separations between services in the definitions were referred to as 'artificial', hindering holistic, joined-up support. A 'divorce' between the practice of care and the regulatory framework was frequently highlighted.

An example of this was some shared accommodation arrangements for three or four people would have to register as a care home and follow all the associated, 'incredibly restrictive' standards, demonstrating a mismatch between the ambition to support 'ordinary and independent living' and the category it has to fit in.

Services experienced barriers when trying to change their model of care 'and don't fit neatly into one of the boxes', which made commissioning new models challenging. However, it was noted that some challenges to commissioning and registration were not well understood 'because people were finding ways round them'. An example of this given by a stakeholder was to describe the service 'in a way that means they don't have to be registered for it', incurring the risk that services could be offering significant support without 'governance or oversight of what they're doing'.

Commissioning and procurement were seen as fundamentally linked to some stakeholders' definition of the workforce, contributing to an environment of commissioning 'on a time and task rather than on a relational and preventative model'. This was seen to perpetuate a tight definition of the workforce, preventing autonomy and being risk averse, features described as 'the antipathist to what social care is meant to be'.

Hindering person-centred care

A number of stakeholders felt the current definitions of care were at odds with areas of legislation like SDS (2013) and the Carers Act (2016). The current definitions are thus seen to hinder person-centred care in different ways. Firstly, they are seen to undermine the SDS legislation and the efforts of integration to deliver person-centred care. This is particularly challenging for the sector as SDS was highlighted several times across the data as demonstrating how it can be used to support people in new ways through the COVID-19 pandemic.

Several stakeholders also felt that SDS was being applied inconsistently across the country as there is a lack of legislative cohesion in the sector.

Stakeholders also reflected that 'what is care and what's not in terms of self-directed support' needed to be unpacked as part of understanding revisions to the scope of the care definitions. Given the flexibility of self-directed support, people are able to choose how they wish to be supported and this might not be through what is traditionally understood as 'care'.

The definitions were seen as not only disjointed from SDS but also the principles of the Health and Social Care Standards of dignity, respect, compassion and quality.

Enablers of SDS – innovation, flexibility, creativity – were seen as restricted and subject to interpretation by local authorities by some stakeholders. The definitions were at times seen as outdated and rigid, geared to 'models of care that do not exist, or do not exist in the same way as they have in the past'. An example of a 'future' model of care that would be limited by current definitions was the hybrid, 'hub' model described by the Residential Care Task Force^[2], which CCPS pointed out would require separate registrations for each component (e.g.. residential care, day care, community-based outreach).

Stakeholders of Disability Equality Scotland highlighted that care services take many forms in practice. They expressed concern, however, that the current broad categories 'could easily lead to one's care needs having to be questioned further than perhaps necessary' in terms of 'proving' a need and financial eligibility.

The 'industry of regulation'

Across the interviews some concerns were raised about the balance between regulation and care. There were also some worries about the conflation between legislation and care assurance and a dominance of regulation over the law which 'shouldn't be based on what the inspection regime is' but vice-versa.

The definitions pose particular challenges for providers registering their services in categories that are not always adequately matched with some services looking to adjust their aims and objectives accordingly. Debates between unregistered providers and the Care Inspectorate, who might feel they should be registered, were also noted. In some cases, creative approaches were taken by the scrutiny body to overcome the limitations of the definitions and meet the needs of the people using the service. An example given reflected on the rigidity of the 'care home service' definition so an innovative approach was taken to enable an older sibling over the age of 21 to remain living with two younger siblings in the same home without having to change the registration to a care home for adults.

Services being registered and inspected separately were seen as challenges to 'inspecting and ensuring quality of a holistic service for an individual'. Similarly, stakeholders also raised the issue of dual registration – where services have to register under different definitions if they deliver different kinds of services i.e. adult and children's services. This was seen as having a negative impact on the ability of local authorities to procure SDS packages that meet individual's needs:

"It's very difficult to get highly specialist children's services to deliver in our area because there's not enough need… and it impacts significantly on individual families [...] and most organisations don't want to try and go for a dual registration because it's just so much more complex and such a lot of hassle" (CSWO).

This was a common theme across the interviews, with stakeholders highlighting how person-led care should not be restricted or diluted by processes or definitions that no longer aligned with a more progressive and aspirational model of care.

Integration – exacerbating the gap between health and social care

Throughout the interviews, there were key questions and concerns about the ways current definitions exacerbated gaps between health and social care and caused barriers to integrated working. Definitions were seen as restrictive in their exclusion of integration and 'divisive' between health and care. For example, one stakeholder pointed out that currently, the schedule stipulates that: 'paragraphs (c) and (d) do not apply where the provider is a health body acting in exercise of functions conferred by the National Health Service (Scotland) Act 1978 (c. 29)'. They argued this was against the spirit of integration and might allow for 'space for people who are not signed up to an integrated way of working'. Creative multi-disciplinary working was seen as stifled by these compounded issues as 'regulation bordered by definition was not helpful in an integrated environment'.

One stakeholder felt that the definitions created an uneven relationship between health and social care and contributed to a 'lack of parity' with health, particularly because health does not have an equivalent set of service definitions. There were nonetheless, differing views on how well the definitions were understood by health colleagues – some felt that 'people in the health service… do not understand all these differences and these variations and the different types of service' while others felt there was a common understanding across integrated services.

Many highlighted the fact that there are a number of pieces of legislation that services operate under. There are also different guidelines which have their own definitions of specific terms and their own vocabulary of care (e.g. Carers Act and the Public Services Reform (Scotland) Act 2010). This further adds to the fragmentation of the sector and prevents effective integration as different services are being shaped by different guidelines, especially between health and social care: 'everyone needs to be reading the same documents, the same procedures, the same protocols, the same guidance'.

Social work and social care

The definitions were seen as not only divisive between health and social care but also across the social services. Separations between 'social work care services' and other areas of the social work landscape' were described as 'artificial' and 'dangerous'. Tensions were outlined between these and other definitions including social services and social work services as well as social care services charged and not charged for as outlined in Section 1 of the Community Care and Health (Scotland) Act 2002.

Some stakeholders felt that while these definitions set out the context of care and where it takes place, it does not define what care actually is in terms of some of the relational or everyday care experiences. The lack of clarity about care also relates to points made about digital support and the need for it to be 'reflected in discussions around what is a care service'. A lack of consistency across Scotland in the way telecare is perceived and registered was also noted:

"In some areas it's registered as a care service...in some it's registered as a housing service, and in some it's the alarm receiving centre, the call handling bit that's registered. In some, call handling is not registered, but the response service is the bit that's registered. And none of that is defined in legislation at all" (TEC).

Some also highlighted the way in which commissioning is skewed in favour of those services that fit in specific areas of the care definitions. This leads to other important areas of delivery to be underfunded because they are not reflected in the same definitions. As a result, statutory duties covered by these definitions are seen to take precedence when it comes to commissioning resources.

Amplifying operational complexity in the sector

The definitions are seen as part of a wider issue in the sector regarding regulated and unregulated services. Discussions of the definitions brought forward the tension between the flexibility of a less regulated sector and the quality assurance of a more regulated one. Regulated services were seen by stakeholders to have more mechanisms of quality control, but the unregulated sector is seen to provide valuable flexibility and accessible alternatives to people using care and support.

Some highlighted that the challenge of operational complexity in the sector is also due to wider sector culture and local interpretations which ties in with discussions about consistency of guidance across the sector.

SOSCN argued for minimum child protection standards to ensure quality of care even among the less regulated sectors of care and support provision. This again reinforces concerns in the sector about the standards of care surrounding unregulated services.

4.2 Challenges for the workforce

Many of the challenges that stakeholders reflected on related to the social care workforce, professional roles and the tension between flexibility, autonomy and standards of care.

Some stakeholders felt that workers do not recognise themselves in the definitions and have to register under categories that are not always the most suitable for them (e.g. those working in housing support or care at home, who are actually working with children, are coming into the Register on parts that actually have a qualification that is more designed towards adults).

Practical operation of the Register

As part of their efforts to future-proof the Register, the SSSC identified key challenges to the practical operation of it, specifically:

• There are 23 register parts containing prescriptive definitions
• Workers employed in combined registered services are required to be registered on both parts of the Register
• There are inconsistencies in how services are registered

Reducing, simplifying and amending the definitions were called for to help address these issues.

Worker roles

Stakeholders recognised that the definitions were 'tied to rigid worker categories' which prevented flexible deployment. They reflected on the shift in priorities towards role flexibility and the need to 'encourage innovative practice around the definition of the care worker'.

Certain roles across health and care were also seen as challenging to integration. In particular, the 'healthcare assistant type role and the social care type role' which was 'starting to be perceived as a barrier to delivering care in the way that integration is intended to achieve'. Unevenly paid roles were also being created as the definitions operationally link to regulation and registration through fees and the rates paid between health and social care workers.

Complicating professional roles between health and social care staff

Stakeholders reflected on how the definitions are part of a wider issue in the sector surrounding workers' roles. Some felt that those working in social care were not always recognised for their role. Others highlighted that those social care workers who are not registered with SSSC do not always have the same access to support, information and training as well as career progression opportunities. Stakeholders acknowledged ongoing tensions between the registered and unregistered workforce.

Many also reflected on the professional distinction between health and social care staff. Some saw this as an indicator of where integration has not fully taken place and some argued this was linked with the lack of integration across guidelines and definitions – Schedule 12 of the 2010 Act included.

Qualification framework

Stakeholders recognised the way in which the definitions interconnected with other systems. Definitions are tied to worker categories on the SSSC Register which are aligned to the qualifications framework. Where the current definitions are not fit for purpose this has a knock-on-effect on worker qualifications potentially becoming unfit for the purpose of the service.

4.3 Challenges for those accessing care & support

Inflexible support

One of the most urgent priorities emerging from the data was the need to address the lack of alignment between the current service-based definitions and flexible, personalised support embodied in the SDS Act.

There were conflicting views on the impact of the definitions on people accessing support. On one level, stakeholders recognised people accessing support might be quite distanced from the wording of the legislation, suggesting that 'their view is, it makes absolutely not a jot of difference what you call it, and therefore do we need definitions?'. On the other hand, they also recognised that where workers were hindered by lack of flexibility, autonomy and creativity in their roles, this would directly impact the person accessing support and the extent to which their care could be personalised.

Transitions

Related to a lack of flexible support, the definitions were seen to make transitions, both for people accessing support and workers moving between services, more challenging. The natural progression for children moving through ages and stages was seen to involve 'lots of different formalities' and 'hoops of regulation'. Processes were seen as separating rather than bringing together support at the expense of the individual.

Transitions from children's services to adult services can be financially impacted in terms of defining resources either 'through the adult care lens or the children's care lens'. An example given was when a young person moving into independence in a residential care or foster care setting can lead to support services finding themselves in a definitional ambiguous area between children and adult services.

In terms of staff transitioning between different service areas, this poses complexity and administrative burden in terms of registration and qualifications.

Geography of care

Stakeholders pointed out challenges with the definitions in the context of rural and remote areas. Some felt the definitions simply 'wouldn't work' in remote and rural areas or needed conditions added to a registration to meet the needs of people accessing a support service.

In particular, where choices for childcare might be limited in rural areas, a childminder might be the only option. As it currently stands in the definitions, childminders should not receive payment for providing childcare to family members and relatives. However, if the childminder has a relative looking to access childcare to receive their 1140 hours of early learning and childcare statutory entitlement, technically they can't do so because of the current definition.

Digital support, absent from the current definitions, also has particular relevance for those in rural and remote areas. The importance of digital engagement to supporting care was further highlighted by the COVID-19 pandemic, with people needing support to access information and services, but also to connect with friends and family.