Review of care service definitions: challenges and recommendations

5. Sector Recommendations

Overall, the stakeholders interviewed were able to identify key changes they saw as necessary in the legislation. Some of them wanted to see specific changes made to the definitions most relevant to them, which would add clarity to the legislation. This included wording changes or adding further qualifiers (see appendix 1 for these types of specific changes). Others felt that more drastic interventions were needed in order to address some of the current challenges in the sector. Many highlighted the need for a person-centred approach to how care is defined and advocated for definitions that enabled services to improve people's wellbeing and ensure an overall good quality of life.

Although stakeholders recognised the need for changes to the definitions, they also acknowledged the difficulties inherent in defining something so complex as care and of future-proofing against a fast-changing landscape with local variation.

This section separates sector recommendations into specific, focused changes, and more aspirational, transformational changes.

5.1 Specific changes to care services definitions

Importance of language

Language was a recurring theme across the interview data. Stakeholders felt it a priority to update the language used in the definitions which was consistently flagged as outdated, and in some cases inappropriate in light of personalisation, human rights and independent living. A rejection of the term 'care' and 'carers', particularly from the disability movement was noted. 'Care and support' as opposed to 'care services' was a more frequently used description. The Three Conversations approach^[3] was highlighted as an example of language that had moved away from service-led terminology towards conversations to understand what really matters to people and families.

Some also felt that the language in some of the definitions carried stigma for those using particular support services. For example, secure care representatives felt the definition of 'secure accommodation' is focused on restricting liberty, as opposed to considering the overall protection and wellbeing of the children that it involves. Similarly, Who Cares? Scotland raised the issue of the language in some of these definitions being disconnected from the experiences and realities of those accessing different kinds of support throughout their lives: 'some of the language and the terminologies that are used to describe children, young people, groups of children, groups of young people, groups of adults – are experienced as quite othering, quite labelling, quite unhelpful'.

Increased recognition of unpaid care

Coalition of Carers stressed the lack of carers' visibility in these definitions and their role as support givers, and suggested a new corresponding category for carers which should look at carer support, and includes carers services like carer centres, short breaks, respite and replacement care. This should be considered alongside the Carers Act to ensure consistency of guidelines.

Creating new categories

Some argued for a more clear delineation between different elements within children and adult services and transitional periods. NDNA highlighted how 'day care' of children currently encompasses a range of categories that are often quite distinct – e.g. day care includes both very young children but also teenagers and children with additional support needs. They questioned whether this could be further split into areas like early learning and out of school care.

SOSCN also considered the possibility of further distinctions in the area of day care between indoor and outdoor nurseries: 'you could actually have an indoor specific registration, or more or less, or an outdoor specific registration'. They also warned however of the knock-on effect this could have in terms of registration with the SSSC and the qualification requirements.

Who Cares? Scotland highlighted the need to include transitional periods in these definitions to ensure that individuals in age categories that were not adequately defined, still received the care and support they needed.

Some also highlighted the need to include areas like kinship care or residential care for children which are not currently reflected in the definitions.

Developing statutory guidance

A number of stakeholders highlighted that one solution to the challenges posed by legislation, especially surrounding lack of clarity and ambiguity, could be to develop further guidance. This could support the existing legislation and clarify what is meant and what are the expectations of the service – and also the mechanisms by which to hold people to account.

Social work academics also argued that guidance could be a helpful place to acknowledge and develop debates and that changing the guidance or schedule rather than the definitions might be sensible.

Broadening definitions of care

Some also highlighted that definitions of the care services could be expanded to reflect a holistic person-centred perspective and include, psychological, social and spiritual needs.

Similarly, the definitions could be expanded to allow for more worker flexibility. Some stakeholders felt that currently, the definitions restrict workers' role and lead to practices like 'salami slicing' where roles are broken down by small tasks i.e. cleaning staff are allocated a small portion of care duties but their pay and title does not reflect that. The definitions could be altered to allow workers more flexibility and a different range of tasks to be reflected in their role.

Others argued for definitions that allow the sector to be less divided between third and statutory areas – both existing on equal grounds. This might involve broadening the scope of the definitions to allow for more choice and control.

Further suggestions included exploring a single definition of a care service, with the Care Inspectorate allowed to bring such regulation as it considered appropriate for that type of service and to specify exclusions. Adding an 'other' option for services that offer elements of the definitions was proposed as a way that could offer flexibility and help to future-proof the definitions.

Having broad definitions covering service areas – adults, children, social work – were suggested by some while others felt it important to 'challenge ourselves as to why some of these categories need to be specifically referenced'. Broad definitions would also still permit the SSSC to link registration to service-specific qualifications.

5.2 Transformative changes to the definitions

Generally, stakeholders recognised that 'tweaking the language' or 'tinkering' around the edges would not achieve the change required and would not help to future-proof the definitions. Exploring 'wholesale change' was seen to be an important way to show commitment to transformation, looking at social care across all legislation. However, views on this differed depending on the level of impact on the stakeholder – those who felt they were not overly affected by the definitions felt that tweaking the language or updating a term was appropriate in their situations. For others, who were impacted by all or most of the definitions, their suggestions tended to be more radical and recognised a need to overhaul the whole system. Some wanted to 'do away with categories all together' and adopt a model which licensed the organisation rather than its services, though overall stakeholders did not advocate removing definitions completely.

When it came to bold changes, the stakeholders all focused on the quality of care provided. Issues of regulation and worker registration were seen as secondary to the key priority of care services which allow people to be supported in the ways that are most meaningful, useful and accessible to them.

'Take a rights-based approach'

Stakeholders argued that the definitions should be fundamentally shaped by a rights-based approach to care and focusing on needs first. NDNA highlighted the importance of focusing on children's needs and defining services from there, an illustration of this being the use of outdoor nurseries as a result of COVID-19. This indicated how a health and wellbeing approach was taken to ensure children had continuous access to the support and care they needed.

Though the importance of a rights-based approach was a common theme across the interviews, another perspective cited feminist ethics and the need to move away from 'rights and rules, towards responsibilities and relationships'.

'Simplify it to make it stronger'

Many felt it was important that the legislative definitions are centred on the people they are meant to serve. This might mean simplifying the definitions to say, 'care is care'. The focus should be less on where it is given, who it is being given to and more on support to live. Unite felt that currently, the definitions allow for loopholes and often fail to protect people when needed. Changing the definitions to be person-centred would put that protection at the core of the legislation. Disability Equality Scotland also highlighted the need for definitions to promote the independence of those using services.

'Focusing on improving wellbeing'

Others highlighted that currently Schedule 12 is weighted towards contested words such as 'vulnerability' and 'needs'. Stakeholders felt that it was important to focus not just on 'vulnerability' or 'health' needs, but also wider, on improving people's wellbeing and outcomes for individuals in general. This might mean finding inspiration in other pieces of legislation like the Care Act (2014) in England which is focused on specific themes around care, wellbeing, health, access, eligibility.

Representatives from IJB also raised the matter of definitions reflecting an 'end-to-end consideration of care'. This meant looking at individuals and their pathways through interactions with services that provide support as a 'whole journey' as opposed to isolated parts. This includes aspects like reablement and preventative care.

'Fit for purpose'

Stakeholders felt definitions need to be updated to adequately reflect the current realities of the sector. For some, this meant the definitions needed to be questioned to ensure they are fit for the sector's statutory duties: 'they should reflect choice and flexibility'.

'Capture experiences from the front line'

Stakeholders emphasised the importance of any next steps being collaborative and inclusive of other key groups missing from the scope of this research. It was consistently acknowledged that it was vital to gather the views of people accessing support and those with lived experience. Existing employees and employers, particularly those who have wanted to innovate outside registration were also crucial to include. Other suggestions were to consult with industry suppliers to find out if the ways in which services are defined hampered how they developed products and entered the market. Engaging those with international expertise on proposed changes was also recommended.

Continual review

Representatives from the Disability Equality Scotland proposed that definitions are reviewed regularly to ensure they adapt to emerging issues and unforeseen circumstances as in the case of COVID-19.