Equality Budget Advisory Group minutes: November 2019

Attendees and apologies

Attendees

• Angela O’Hagan, WiSE, Glasgow Caledonian University (Chair)
• Lorna Ascroft, Scottish Government Programme Lead for Reform of Adult Social Care
• Shaben Begum, Scottish Independent Advocacy Alliance
• Tressa Burke, Chief Executive, Glasgow Disability Alliance
• Fiona Collie, Carers Scotland
• Emma Congreve, Joseph Rowntree Foundation
• Liz Hawkins, Scottish Government Communities Analysis
• Ali Hosie, Scottish Human Rights Commission
• Mirren Kelly, COSLA
• Tom Lamplugh, Scottish Government Office of the Chief Social Policy Advisor
• Isla McIntosh, Glasgow Disability Alliance
• Hannah Tweed, Health and Social Care Alliance
• John Wilkes, Equality and Human Rights Commission
• Stuart Wilson, Scottish Government Health Financial Accounting and Planning (for item 2.1)
• John Wood, Chief Officer of the Health and Social Care team , COSLA
• Gillian Achurch, Scottish Government Communities Analysis (Secretariat)

Apologies

• Hugh Buchanan, Scottish Government Public Spending Division
• Tim Ellis, Scottish Government Performance and Outcomes Division
• James Fowlie, COSLA
• Uzma Khan, Scottish Government Office of the Chief Economic Advisor
• Anne Meikle, Scottish Women’s Budget Group
• Richard Robinson, Audit Scotland
• Sean Stronach, Scottish Government Equality Unit

Items and actions

1. Introduction & minutes

Angela introduced the meeting. This is part of a series of deep dives that the Group is holding.

The minutes of the previous meeting were provisionally approved.

Actions

• Gillian to confirm no further corrections to minutes of the previous meeting.

2. Deep dive on Health and Social Care

2.1  Overview of the Health and Social Care Medium Term Financial Framework (MTFF) 

Stuart offered an overview, including how the growth is affected by price increases, demographic growth and resource requirement growth. The framework includes a 1% efficiency target year on year, in line with NHS England.

Angela drew the Group’s attention to the significant £1.8bn residual gap and the emphasis on the setting in which care is delivered, with proposals to deliver care and support in communities. There are concerns about meeting need. She asked what equalities analysis was conducted as part of producing the MTFF. Stuart noted that he would follow up with colleagues to provide an answer.

John Wood noted that in terms of integrated health and care, responsibility for planning and delivery lies with Integrated Joint Boards (IJBs) and Chief Officers, and analysis happens at this local level. There are duties to involve the community, and work is done to ensure that commissioning plans have a strong economic inequalities focus. 

Liz  asked whether it is normal that almost all unit costs are going up in the MTFF including lines such as birth in hospital. Stuart confirmed that this is normal, and that the MTFF attributes this to a mix of general pay increases (and more specifically, from the living wage commitment in social care), further Government intervention, and market forces.  Lorna added that  anticipated greater growth in the use of social care is also included in the projections.

Angela asked how the savings sit alongside the projected increases. John Wood suggested that the 1% saving was inevitably hard to arrive at accurately, but that it is assumed on the basis of investment in public health – a prevention approach. Emma added that prevention is important, but that we also know there is a big link between low income and health issues, and that it would be good to see the contribution that tackling poverty can make to savings acknowledged in documents like this.

Tom noted that the MTFF was published in October 2018, and that uncertainty around projections was flagged. He asked whether there are intentions to revisit the document soon, and if so, what the strategic decisions are? Stuart responded that SG is committed to refreshing the framework, although he does not think there is a firm timeline for this. John Wilkes noted that if impact assessments were not done previously, then this refresh would be an opportunity to do so.

Angela asked about read across between the MTFF and the NPF, and Stuart stated that the reforms in health and social care are fundamental to the NPF objectives.

Actions

• Stuart to feed back in responses to the following questions:
  • What equalities analysis was conducted on of the MTFF?
  • What is the timeline for refreshing the MTFF?

2.2 Governance and funding of health and social care support

The Group discussed the governance and funding of health and social care support. Tressa asked how possible it is to shift resources to prevention given the pressure at the provision end. John Wood suggested that from a strategic point of view, sometimes it is necessary to start by freeing up funds from acute services and transferring these into communities for innovate services. Fiona highlighted a need to think about how bodies work together, since NHS decisions impact on both community decisions and local authority (LA) services. She suggested that at the moment this still feels like it is planned in silos. 

John Wood gave an overview of IJBs, their requirement to involve communities, and to have regard to equalities. 

Angela noted that strategic commissioning does not take the traditional approach of just asking whether to adjust or continue what has been done in the past, but instead focuses on outcomes. EBAG is interested in the ownership and direction of equalities analysis in relation to this. John Wood noted that although equalities analysis sits with IJBs, Chief Officers and their team, this is not consistent nationally.. He added that some IJBs are still getting their head around population health, deprivation and inequalities. He highlighted Dundee as a good example of an IJB and Chief Officer understanding the impact of poverty and inequality, specifically on drug deaths.  

Lorna added that in Dundee they have started to tailor teams to the locale, understanding the issues of different communities, and to engage with how people use services. She suggested that they are using data and evidence very effectively.

2.3  Adult social care support 

Lorna gave an overview of what social care support is, current policy and the ambition of the reform of adult social care programme, including the focus on co-production and the need for new data and evidence. The Reform of Adult Social Care team have been working with COSLA to ask people about how they define social care, and what it should look like. There is no consensus around what social care is and people generally only know about it if they have had an interaction with it. Many people assume it is free at point of contact, like the NHS. Most of the response has been quite negative, in terms of the burden of care and soaring costs. The team therefore see a need for a different conversation and understanding. 

One driver for this work is the human rights aspect of the Social Care (Self-directed Support) (Scotland) Act 2013, which states that people have the right to choose how they live their life. Lorna noted that there is variability in terms of how this has been taken up, and that while Self-Directed Support (SDS) has been seen as separate. really it has been developed as part of delivering social care in this way. 

Shaben asked whether there had been discussion of procurement and commissioning, and Lorna said that there have mainly been comments that people are not getting the support they need, and that providers are seeing a move towards big procurement exercises. Shaben asked how good engagement is, and Lorna responded that there are pockets of good engagement, but that this is not consistent. She will check in with colleagues and feed back on examples of innovative commissioning. 

The Reform of Adult Social Care team have produced a circular diagram illustrating the programme priorities set by the policy panel, made up of people who use support and carers. Lorna believes it is important to raise the profile of social care support, since more investment is key and this requires the population to be on board. She highlighted that this is about implementation rather than policy, and that we need to think differently about care and support because the current model is not going to be sustainable in the long term, with population changes. 

Lorna noted that currently the data and evidence is not great in terms of the delivery and outcomes of health and social care. The team have reviewed this and are currently producing proposals for how best to take this forward.

Actions

• Gillian to circulate Lorna’s presentation and the link to the Social care support reform: vision webpage.
• Lorna to confirm with colleagues how good engagement is and feed back.

2.4  Round table discussion

Emma asked where the funding for social care comes from. Lorna responded that it comes via local government (although decision making is the responsibility of IJBs), so SG does not determine how much is spent. However, where there are new policies there will often be new money added. Ali suggested that there is one line in the national budget for SDS, and that it has been reducing. Lorna clarified that that budget is for a development programme, rather than the money to deliver SDS, and that it has not reduced in real terms.

John Wilkes asked how much of the overall budget ends up with individuals. Lorna said that currently we do not have this information, but that there are plans to ask LAs to report the personal budgets they set. She added that historically, LAs have been asked to collect information by service type, but with SDS they are asked to collect it by person. Some have made this switch, but not all. John Wood noted that there is a local government benchmarking framework, undertaken by the Improvement Service, with a line tracking the spend that flows through into personal budgets. However, Lorna cautioned that this is only direct payments. Shaben noted that proportionately, only a small number of people are accessing SDS, and that it is necessary to have quite a lot of personal capacity to access it. Lorna suggested that it is important to give people working in these services support to be truthful about the system’s failings. 

[Post meeting note: social care national data found that of the total number of people receiving social care services/support in 2017/18, an estimated 75% were involved in choosing and controlling their support through self-direct support options. https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Publications/2019-06-11/2019-06-11-Social-Care-Report.pdf ]

John Wilkes asked whether there could be another way of getting the money directly to people, with the expectation that service provision would grow in response to this. 

Isla proposed that in the context of shifting the balance of care, social care should also be seen as part of prevention, and that public conversation will be vital in that. She suggested that there is no equalities analysis at local level of the cuts made to social care funding, and that EqIAs tend to say that there is no equalities impact because cuts will affect everyone equally. 

Tom asked whether there will be the opportunity to involve people in the design of new data collection proposals. Lorna confirmed. Ali highlighted some European survey work and ONS work looking at evidence around social care which might be helpful. Fiona supported the use of wellbeing indicators and following the money, noting that there are very rarely measures of the impact on carers, although this is important especially since the numbers of people providing intense care is increasing. Lorna agreed that there’s a need to measure harm, rather than only thinking about the risks of implementing a service or not. 

Angela highlighted the need to value care and those that provide and receive it, and to recognise it as a social and economic investment. She proposed that EBAG’s challenge is to decide how to encourage this equalities analysis as a positive approach to policymaking. Isla suggested that there is a need to strengthen EqIAs and the equality outcomes set by Health and Social Care Partnerships. She noted that when GDA have queried EqIAs they have been told that there is no official requirement on quality.

Tom noted that he was also surprised to see no mention of equalities and the Fairer Scotland duty in the MTFF, and that he will follow up with them and feed in to the refresh. Liz also expressed surprise that there was no mention of women or equalities in the NHS workforce document mentioned in MTFF. John Wilkes noted that EHRC’s assessment of the Equality Duties has found a nervousness about looking at particular groups, and a tendency instead to focus on overall equality (which is not the intention). 

John Wilkes supports rethinking the MTFF, thinking of this as investment rather than a cost, and considering whether we should redirect resources to the 780,000 ‘unpaid’ carers in Scotland. He asked whether there is a tension about simultaneously providing services and giving money to people to buy those services. Lorna suggested that the public sector also have a responsibility to make sure that there is a diverse ‘market’ and a range of different types of support. 

Tressa expressed support for the work being done on reforming adult social care, especially the focus on wellbeing and quality of life, and suggested that who captures indicators is really important, as is knowing where the money goes. She noted that in Glasgow, older people do not currently have a choice, because there is only one provider of social care, which is not SDS as it was intended. Fiona added that alignment in measurement is important, since currently there is a focus on measuring wellbeing outcomes in social care, but targets in the NHS. 

John Wood noted that there is a reluctance at national/IJB level to take third sector data seriously, which is a problem since often it is collected at national/IJB’s request. Ali agreed with this point and the importance of not dismissing evidence of harm as anecdotal. John also added that IJBs often claim a limited capacity to engage because they are financially squeezed. He also highlighted a dearth of third sector presence in many areas of Scotland, which might be an area to consider investing more resource. Lorna noted that there are also examples where partnerships have gone out and engaged and supported people to set up the organisations that they want. She added that COSLA and the Cabinet Secretary for Health and Sport have committed to producing guidance on community engagement in health and social care services, which will focus on the need for continuous engagement.

Emma noted that health and social care do not sit in isolation and that it might be useful to better map across to different parts of government policy, such as disability employment, social security and the gender pay gap, and understand the links.

Angela drew conclusions:

1. The narrative on understanding social care and the links to other areas are important;
2. While funding may be finite, we need to view those resources as public, and as public investment;
3. It is key to understand the nature of structural inequalities, and how these are recognised in accessing or not accessing care;
4. There is an issue around the competence and quality of impact assessments, and often an absence at macro level.

 Angela thanked all for their input.

Actions

• Ali to share links to the European survey work on social care and the ONS work looking at evidence around social care and what it means to live independently.
• Tom to follow up with Health Finance and input into the refreshed MTFF.