Consultation response: A National Care Service for Scotland
Response ID ANON-YV7S-5CV8-Y
Submitted to A National Care Service for Scotland Submitted on 2021-10-21 14:51:04
1a Improvement
What would be the benefits of the National Care Service taking responsibility for improvement across community health and care services? (Please tick all that apply)
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Are there any risks from the National Care Service taking responsibility for improvement across community health and care services?
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Our ESRC-funded research on social care in the four nations of the UK, has highlighted that there is huge variety in local care systems. However often this relates to features of local labour markets, demography and geography rather than the formal systems in which they are located. For example, coastal towns or rural villages across the UK have more in common with each other than they do with their nearest urban centres. A national approach to commissioning in Scotland risks being insensitive to these local care systems in seeking to standardise provision across Scotland. Local differences will persist (as they do in the NHS) but rather than defending and celebrating this diversity they will need to be hidden by claims of national consistency. We see no evidence to support the claim that commissioning at a national level will be better than the local commissioning which currently goes on.
We have concerns that standardised commissioning practices will be restrictive of the local discretion which is required for commissioners to respond to local need at a population level. It risks limiting the scope for commissioners to support providers to innovate and tailor support to individual outcomes. According to our NIHR-funded research on care markets, what national support can do best is to build the technical and relational capabilities of local commissioners. Limited local authority capacity and high staff turnover in commissioning has made it difficult to build good relationships and sustain trust. We suggest that more work is done to bring together local authority staff (encompassing procurement/legal teams as well as commissioners) with providers in initiatives to build trust and facilitate opportunities for co-design. We also suggest that more work is done to build market-shaping capabilities among elected councillors who hold a social care portfolio.
A second risk is that the language of a National Care Service may raise public expectations, believing that this now operates as an NHS for care. Given the ongoing charging for 'hotel' costs in care homes and the continued use of private and third sector providers it is unlikely to feel like an National Care Service in the way that the language suggests. This risks adding to the confusion which already exists in Scotland about the 'free personal care' arrangements.
1b Access to Care and Support
If you or someone you know needed to access care and support, how likely would you be to use the following routes if they were available?
Access to Care and Support - Speaking to my GP or another health professional.:
Access to Care and Support - Speaking to someone at a voluntary sector organisation, for example my local carer centre, befriending service or another organisation.:
Access to Care and Support - Speaking to someone at another public sector organisation, e.g. Social Security Scotland:
Access to Care and Support - Going along to a drop in service in a building in my local community, for example a community centre or cafe, either with or without an appointment.:
Access to Care and Support - Through a contact centre run by my local authority, either in person or over the phone.: Access to Care and Support - Contacting my local authority by email or through their website.:
Access to Care and Support - Using a website or online form that can be used by anyone in Scotland.:
Access to Care and Support - Through a national helpline that I can contact 7 days a week.:
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How can we better co-ordinate care and support (indicate order of preference, with 1 being the most preferred option, 2 being second most preferred, and so on)?
Better coordinate care and support (ranked) - Have a lead professional to coordinate care and support for each individual. The lead professional would co-ordinate all the professionals involved in the adult’s care and support.:
Better coordinate care and support (ranked) - Have a professional as a clear single point of contact for adults accessing care and support services. The single point of contact would be responsible for communicating with the adult receiving care and support on behalf of all the professionals involved in their care, but would not have as significant a role in coordinating their care and support.:
Better coordinate care and support (ranked) - Have community or voluntary sector organisations, based locally, which act as a single point of contact. These organisations would advocate on behalf of the adult accessing care and support and communicate with the professionals involved in their care on their behalf when needed.:
How should support planning take place in the National Care Service? For each of the elements below, please select to what extent you agree or disagree with each option:
Not Answered Not Answered Not Answered Not Answered Not Answered Not Answered Not Answered Not Answered
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The Getting It Right For Everyone National Practice model would use the same language across all services and professionals to describe and assess your strengths and needs. Do you agree or disagree with this approach?
Not Answered
Please say why in the text box below:
The Getting It Right for Everyone National Practice model would be a single planning process involving everyone who is involved with your care and support, with a single plan that involves me in agreeing the support I require. This would be supported by an integrated social care and health record, so that my information moves through care and support services with me. Do you agree or disagree with this approach?
Not Answered
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Do you agree or disagree that a National Practice Model for adults would improve outcomes?
Not Answered
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1f Residential Care Charges
17. Most people have to pay for the costs of where they live such as mortgage payments or rent, property maintenance, food and utility bills. To ensure fairness between those who live in residential care and those who do not, should self-funding care home residents have to contribute towards accommodation-based costs such as (please tick all that apply):
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18. Free personal and nursing care payments for self-funders are paid directly to the care provider on their behalf. What would be the impact of increasing personal and nursing care payments to National Care Home Contract rates on:
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We are concerned that without a significant increase in funding for social care, any increases in payment to providers will lead to more rationing of services . This has been the broader pattern with 'free personal care', with an increase in waiting times for care and an increase in the severity of need which qualifies for support.
19. Should we consider revising the current means testing arrangements?
Not Answered
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Chapter 2: National Care Service
20. 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 Please add any comments in the text box below:
As we indicated earlier, we think that national consistency in social care risks trying to standardise types of support that should be as local and person-centred as possible.
Complexity and fragmentation is an inevitable part of social care provision, given the multiple different stakeholders, the wide variety of types of support that people require to live a flourishing life, and the intersection of care with other systems such as housing and employment. Trying to standardise commissioning risks trying to design out this fragmentation and complexity.
From our care market research we are not convinced that complexity inhibits service improvement. Care is best delivered by a multiplicity of providers and that as a result some fragmentation and complexity is inevitable. This need not inhibit quality, or the achievement of outcomes for people who use those services. Indeed, the institutionalised state-run social care systems of the past could be described as ‘simple’, but they did not facilitate high quality support that enhanced wellbeing. Whilst oversupply of providers can lead to a lack of focus on quality and a race to the bottom in terms and conditions, undersupply and a small number of providers can lead to stifling of innovation and can minimise voice and control of people using services.
21. Are there any other services or functions the National Care Service should be responsible for, in addition to those set out in the chapter?
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22. Are there any services or functions listed in the chapter that the National Care Service should not be responsible for?
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Chapter 4: Reformed Integration Joint Boards: Community Health and Social Care Boards
58. “One model of integration… should be used throughout the country.” (Independent Review of Adult Social Care, p43). Do you agree that the Community Health and Social Care Boards should be the sole model for local delivery of community health and social care in Scotland?
No
Please say why in the text box below:
We are concerned that integration becomes the focus of the NCS, leading to excessive focus on alignment with health and not enough on aspects of social care that are about prevention, wellbeing and self-direction.
Self-directed support in Scotland has not taken off as effectively as it should have done and we see part of the reason for that as being the emphasis given to integration with health. An interviewee in a Scottish integration authority told us that the focus had been on NHS discharge because this was the metric on which they were measured, and that as a result there was less emphasis on self-direction, prevention or on other ways to use social care to help people attain wellbeing. We are concerned that a standardised integration model will reinforce the message that social care exists to facilitate NHS hospital discharge rather than to allow people to live flourishing lives within their communities.
59. Do you agree that the Community Health and Social Care Boards should be aligned with local authority boundaries unless agreed otherwise at local level?
Not Answered
60. What (if any) alternative alignments could improve things for service users?
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61. Would the change to Community Health and Social Care Boards have any impact on the work of Adult Protection Committees?
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62. The Community Health and Social Care Boards will have members that will represent the local population, including people with lived and living experience and carers, and will include professional group representatives as well as local elected members. Who else should be represented on the Community Health and Social Care Boards?
63. “Every member of the Integration Joint Board should have a vote” (Independent Review of Adult Social Care, p52). Should all Community Health and Social Care Boards members have voting rights?
Not Answered
64. Are there other changes that should be made to the membership of Community Health and Social Care Boards to improve the experience of service users?
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65. “[Integration Joint Boards] should employ Chief Officers and relevant other staff.” (Independent Review of Adult Social Care, p53). Currently, the Integration Joint Boards’ chief officers, and the staff who plan and commission services, are all employed either by the local authority or Health Board. The Independent Review of Adult Social Care proposes that these staff should be employed by the Community Health and Social Care Boards, and the chief executive should report directly to the chief executive of the National Care Service. Should Community Health and Social Care Boards employ Chief Officers and their strategic planning staff directly?
Not Answered
66. Are there any other staff the Community Health and Social Care Boards should employ directly? Please explain your reasons.
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6c Market oversight function
78. Do you agree that the regulator should develop a market oversight function?
Not Answered
79. Should a market oversight function apply only to large providers of care, or to all?
80. Should social care service providers have a legal duty to provide certain information to the regulator to support the market oversight function?
Not Answered
81. If the regulator were to have a market oversight function, should it have formal enforcement powers associated with this?
Not Answered
82. Should the regulator be empowered to inspect providers of social care as a whole, as well as specific social care services?
Not Answered
Please say why in the text box below:
Our NIHR-funded research on care markets highlighted that in England the role of the CQC in market oversight creates an incentive for more use of block contracts which stabilise the market, in place of self-directed options which are perceived to increase market fragility. This tension should be considered - in dialogue with the CQC and with SDS teams - as part of determining the appropriate role for the regulator.
7d Personal Assistants
94. Do you agree that all personal assistants should be required to register centrally moving forward?
No
Please say why in the text box below:
We feel that decisions on this should be steered by the Disability Rights movement who have usually argued that self-direction means that they should be able to employ who they want, rather than being required to employ people from a register. Research into the registration of personal assistants by Vanessa Davey at LSE concluded:
"In terms of safety, available data suggests that existing measures to ‘regulate’ personal assistants are proportionate to the level of risk. There is no evidence of greater referrals for suspected abuse where PAs are employed. Levels of training among PAs are slightly lower than other care workers, but less so when temporary workers or family and friends are discounted." This blog, drawn from Vanessa's research into this topic sets out the issues well: https://www.thinklocalactpersonal.org.uk/Blog/Regulation-of-care-workers-should-personal-assistants-be-included/
95. What types of additional support might be helpful to personal assistants and people considering employing personal assistants? (Please tick all that apply)
96. Should personal assistants be able to access a range of training and development opportunities of which a minimum level would be mandatory ?
No
About you
What is your name?
Name:
Professor Catherine Needham
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Email:
c.needham.1@bham.ac.uk
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Individual
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