Adult social care: independent review - easy read version

Independent Review of Adult Social Care in Scotland - Easy Read

Introduction

The Scottish Government asked for an independent review of adult social care in Scotland. 

The Covid-19 pandemic has made people think about social care support that is given in care homes. This review makes recommendations about care homes. But it is important to remember that most social care support is given in people's homes and in local communities. We want that to continue. 

Covid-19 has made us think about part of the social care system but we need to think about the whole system.  A lot of the challenges we talk about in this review were with us before Covid-19. They will still be here after if we do not sort them. 

We know that social care affects the lives of many different people and places. We have tried to be inclusive when thinking about people's experiences.

In Scotland a lot of social care support is good and should be celebrated. Many of the things we need are in place to make things better. 

Adult social care support does not stand alone. It has strong links to social work, children's services and the wider services.

But we can do better. There is a gap between how we want things to be and how it is done.

The system we have now is not getting the results we want. So we need a new system.

How we think about Social Care

We need to start by changing the way some people think about social care support.  There are challenges, and this report recognises these.

Good social care is important for everyone in Scotland. It is a good investment in our economy and citizens.

We will not grow to have the best social care support in Scotland without a new system. We need a National Care Service to get the best and the same results for people.

We will set national standards, terms and conditions. We will have national rules and management. We will bring everyone together to reach the same goal.

We also need to change the way we plan and buy social care support. We need to do this is a way that builds trust. We need to build partnerships.

We have to listen to people who have lived experience at every level. We have to create our new system with the people who use it.

What we Heard - Key Themes 

Assessments

Good social care services and support can have a positive impact on people lives. People spoke about positives such as dedicated social care staff, support enabling people to live and services working together.

But we also heard a lot of frustration about social care. People feel that the term social care can be used in a negative way.  People think it only means for crisis situations. Social care support should be seen as something that supports people to achieve their goals and outcomes. 

The current system can seem confusing. It causes worry and anxiety. People may not get or cannot afford support. This is not the way people who need support should be treated. 

Family may have to help with care. They may have also have to work. Some may have a difficult financial position.

For staff it can cause stress if they must always respond to crises. They may feel that they are not doing enough.

People said the process of accessing social care was difficult and complicated.  People told us that they had to fight for support. 

Eligibility was described as one of the main barriers to accessing social care. Support is only available when people are very unwell or in crisis. We heard about the negative impact this has on their mental and physical wellbeing.

People said the process is looked at in a medical way. It is too complex and takes too long. Some social workers were described as not having enough training in all difficulties.

To improve, people told us that social care needs to focus on a person's wellbeing and how things change. It should not focus on what is done and money. 

It should be flexible to change as needs do. It should take account of wider supports in a person's life, such as the support of carers and local services.

Assessment should be simple with the person at the centre.

Design of services

We heard that changes in health and social care have made it better. But there is still more to do. People need to be more involved in planning their own care, and in making decisions about local plans for services and supports.

National and local services need to work together better. Moving from children's to adult's services must improve. Other services such as transport, housing, education and employment should work together better.

It was frustrating to repeat the same information to different professionals. If we agree to share information this would stop this. We were told we need to think more about technology and information sharing to improve people's experience.

Technology can help people live independently and support them but it should not be used in place of other kinds of care. It is not a replacement for support provided by another person. 

How services are planned and paid for

People told us that Scotland has good laws and guidance for services. However things do not always happen in service delivery. There was a difference to service delivery in different areas.

Planning and paying for services sometimes had poor outcomes for people. People felt that Integration Joint Boards had made improvements on this but many people had serious concerns.

We heard that the way services are planned and paid for makes unhelpful competition. This makes the process focus on cost. We want it to focus on working together for high quality, person-centred care and support. The focus on costs causes poor terms and conditions, including pay, for the social care staff.

Social Care Staff

People told us social care staff are motivated and proud of their work. However serious concerns were raised. 

People were worried about staff being undervalued and underpaid.  People also spoke about a lack of support and training opportunities. This can have serious consequences for people who use services. 

Unpaid Carers 

Unpaid carers want to care, and care well. But like support care staff they told us that they are undervalued.

Unpaid carers need support to help them care. They often do not know their rights and the support available. Accessing support can be complex, takes too much time and is frustrating. 

Carers told us that respite is not always viewed as essential support. Without respite some carers do not get breaks. This cannot go on. It is unfair and limits their own life. 

Equality 

Equality was raised a lot.

Some people who use social care support told us that they had found it hard to have their rights upheld  and sometimes had to pay to access basic services to meet their  human rights. Human rights are rights that every human should have. This was for normal day-to-day activities such as washing and getting dressed, and going to work. 

We heard about unfairness in services largely provided by women and choices of people from minority ethnic communities not listened to.

Communication support for people with sensory impairments and learning disabilities can be poor.  

The negative attitude and stigma toward supports for mental health problems, addictions and criminal issues should be sorted. 

Areas for Recommendations 

A Human Rights Based Approach

We asked people about respect for their rights when using social care services. We heard examples of where human rights had been put at the centre of services. Staff and supported people felt valued and had their rights supported. 

We also listened to good experiences where people were managing their own budget. They put in place the support they wanted that helped them to live full lives. 

However, we heard from many people that their human rights were not respected. There was not a focus on supporting independence and taking part in decision making. 

Unpaid Carers

Caring is normal. Many people will be carers at some point in our lives, A carer does not need to be living with the person they care for and can be any age.

More options should be developed for both the supported person and unpaid carers. It should better meet needs and choices.

The case for a National Care Service (NCS)

 Care home owners are responsible for care homes along with Councils who make arrangements for people to move to a care home. The pandemic has shown the public expect the Scottish Government to be responsible for social care.

We think Scottish Government Ministers should be responsible due to the impact on people's wellbeing. Social care also has links with NHS services.

Councils should still be important providers of social work and social care services. They will remain partners in Integration Joint Boards, where they will continue to work with the NHS and others to meet local need. Councils also provide many other services important to social care, such as housing. 

A National Care Service will allow equal access to high quality services.

There should not be differences in care that reduces or harms people's life experiences.   

There should be a focus on preventative and early intervention support. There should be a move away from crisis support.

When someone has been assessed for care they should be able to move to another area and take their  assessments and support plans for social care support with them. 

We considered whether adult social care should move to public ownership and management. Public ownership is when the state – national government or local government, or other government bodies – run an industry. We found this would not improve outcomes for people using care. 

Recent evidence suggests that quality of services in communities is often highest among third sector providers.  During the pandemic there is evidence that smaller care homes also had a higher quality of care.

We looked at how much it would cost for public ownership. It would be very expensive and take a lot of time. Time could be better spent working to improve care. We have also looked other issues such as unmet need for social care supports. We think this should be the more important to spend money on.

A National Care Service – how it should work

Local planning and delivery of support should continue. It should build on the progress made. Integration Joint Boards should take more responsibility for the planning and delivery of adult social care support. They will then report to the Scottish Government as part of the National Care Service. 

Budgets should be decided nationally and given directly by the Scottish Government to Integration Joint Boards, which will deliver services locally.

The National Care Service should have a board with a Chair.  The board should include social care staff, people with experience of using social care support, unpaid carers and providers.

The National Care Service should have a Chief Executive. They should report to the National Care Service national board.

Models of Care

We want to reduce institutional and residential care. We have an aging population so this needs urgent action 

We should not just build more care homes. Most people say they would like to live in their own homes for as long as possible.  Moving into a care home must be the informed choice of the person requiring care and support. 

As we find new ways of providing care at home and in local communities there is a need for services that can provide extra care as alternatives to hospital and residential care. 

There are new ideas for adults and older people who have more complex needs to remain in a more homely setting where extra care is provided. Services need to work together to develop these.

We want to support people to stay in their own homes and communities for as long as possible. We must improve and adapt those homes to support a better quality of life. Even small adaptations can have large improvements.

The role communities play in supporting adults to remain active is important. There are many community based services that provide important advice and support to adults and unpaid carers.  They can make a huge difference to people's quality of life.

Social connections are important to everyone's wellbeing. Transport is important for many people to access of support.

Planning and buying social care services for public good

Many people believe this needs to change and be done differently. It could make things fairer, rights based and improve social care support. It could increase standards and improve outcomes. 

At the moment this process is not trusted and is too competitive. 

Arranging services should be not only be based  on money, although we know money is important. Other factors should be terms and conditions of staff, training and support for staff and the condition of buildings, flexibility of services and improving people's experience of the quality of care. 

 The requirements for arranging and buying services should include investment in improving the quality of care, and in staff terms and conditions – and in improving the choices and quality of care. 

Information about unmet need should be added to plans.

Planning services should clearly show how people's rights have been taken into account. Local plans should involve organisations and individuals in the process. 

During the Covid-19 pandemic, a great deal of attention has rightly been given to care homes.  Care homes that have reduced outbreaks of Covid-19 have been smaller, locally run, staffed and worked in partnership with other local services.

The issue of private care homes making a profit was raised as a concern. Large amounts of money leave some care services and go to investors. This money could be better used to raise standards of care and terms and conditions for staff. We therefore recommend that the National Care Service should take these concerns into account as part of its development.

Fair work

We heard about the commitment of the social care staff in supporting people. But we also heard staff are undervalued and badly paid, seen as lower skilled than health staff, poorly supported in terms of learning and development, and under-represented.

Turnover of staff is high and employing people can be hard. It is difficult to maintain and improve standards with poor training and development. We need to plan ahead for training, employing and keeping staff. We need to work with partners in health and housing. 

A national job evaluation programme should be done. This will find out the value of the skills and responsibilities of social care.

Finance

These ideas come with a cost. But they are not only about cost. Social care support is not a drain on money. It creates jobs and economic growth. It enables people who access care and support, and their carers, to find and keep a job. 

Costs now happen as services manage crisis. Not enough is done to prevent problems and empowering people to live full lives. 

There is a commitment to  increasing staff to the Real Living Wage of £9.50 per hour in 2021.

We recommend removing charging for non-residential social care support and more people may use it. People should not be charged for non-residential social care support such as care and support at home, and day care. Care home residents should only pay accommodation costs.  It is fair for some charge to be made for accommodation costs as most people have to pay this to live somewhere.

People access healthcare free at the point of need but are charged for social care support. This does not support delivery of their human rights. 

Key Recommendations:

• Human rights should be at the heart of a new social care system.

• A National Care Service for Scotland should be set up so that it is equal to NHS Scotland, with both reporting to Scottish Ministers.

• The National Care Service's job should be to make that all service users, their families and carers get the same level of care and support.  The National Care Service should also be in charge of employment and training of care staff and giving them better working conditions.

• Self-directed support must work better for people, with decisions based on their needs, rights and preferences.

• The safety and quality of care given in care homes must be made better. It should be the same standard in every care home.

• Social care support should focus on enabling people to stay in their own homes and communities. This will help them to make social connections and to have control over their lives. 

• People who are in charge of services should include people with lived experience, unpaid carers, local communities, care providers and others in planning and making decisions. They should work together with a focus on people's rights.

• The Independent Living Fund should be reopened and reviewed.

• Ways to use new taxes to pay for adult social care support should be looked at.

• Assessments should be replaced by a supportive process involving good conversations with people who need support.  
• Carers need better support to carry out their caring role and to take a break from caring with access to good respite care. The Carers Act should be changed so that respite care is one of their rights. 

• A review of financial support made available to unpaid carers should be taken forward. 

• When things do not work well for people they must be able to make a complaint. There must be a good system in place to deal with complaints quickly.

A complete list of the Review's recommendations can be found in the main report.