Adult social care: independent review

Chapter 8 Models of care

"A person-centred approach to social care support must be premised on ensuring citizens are able to fully exercise autonomy and choice in the supports available to them, which includes clear and defined resources directly available to citizens and a strong, healthy and diverse suite of support options tailored around the needs of local communities.”

We heard about some excellent examples of innovative work that is improving people's experience of care and support while local systems maintain core supports and services. However, innovation seems usually to be the result of a combination of enthusiastic local leadership, availability of additional funding and willingness locally to change. We heard little to suggest consistent efforts to share learning, scale-up or spread approaches that work well. The current system seems to support local innovation rather than widespread improvement, which is why we have made specific recommendations about prioritising improvement programmes for self-directed support, and commissioning and procurement.

Examples of the kind of improvements that people are trying to make include:

• Reducing use of institutional/residential care
• Making better use of adaptations and technology
• Involving people and their families more in decisions
• Including wider community supports in care
• Professionals working together better across traditional boundaries of health, social care support and other services such as housing.

We have not called this chapter "new" models of care because Scotland has been committed to these approaches for the last 30 years. The problem is not that we do not have good ideas; it is that we have not acted on them at scale and with genuine commitment. We seem to rely too much on bottom-up developments that we expect to flourish without systemic support. We have summarised a few of the good ideas and good practice examples we have heard about over the last few months, below. This is by no means a comprehensive description of "what good looks like". It is just an illustration that Scotland does not seem to be short of inspiration, and can learn from other places – but we have not bridged the gap between these good ideas and consistent access to the best quality social care supports for everyone.

Reducing use of institutional/residential care

Given the demographic trends, including the projected growth in diagnoses of dementia, this needs urgent attention. We do not believe that the answer to those demographic challenges lies in building additional care homes. Most people say they would like to live in their own homes for as long as possible. Nonetheless, people told us that there is still an almost automatic default to care home care in some areas, particularly for frail older people. This observation is especially striking in light of our human-rights based approach: moving into a care home must always be the informed choice of the person requiring care and support. We are concerned that at times the emphasis on residential care for older people is counter to that fundamental right to choose and is sometimes suggested because care at home can be more expensive. Alternatives exist beyond the traditional choice of care home/care at home, a few of which we outline here.

We heard about extra care housing from Moray, Scottish Borders and South Lanarkshire. These combine private housing space with communal facilities, on-site care and dedicated nursing support. Fewer people with learning disabilities live in care homes, with most using Supported Living arrangements. Although designed for different needs, this model is not so different from extra care housing for older people: it enables the person with learning disabilities to live alone or with other people of their choosing, in their own home with an onsite team providing 24 hour support.

The Shared Lives model takes a different starting point, with approved carers welcoming adults who need day support or longer term care into their own home. This model is currently used, most extensively in Scotland in Fife, to support a range of people, particularly people with learning disabilities, but it could be extended to offer respite to unpaid carers of frail older people and utilised more extensively across Scotland.

For older people, there is also potential in a Home Share model, in which someone facing a housing challenge – for instance a younger adult or student – provides companionship and practical help with tasks like shopping and cleaning in exchange for low-cost accommodation. Arrangements like this are overseen by a management company for the protection and assurance of everyone involved.

As we find new ways of providing care at home for more people, there is likely to still be a need for facilities, where care at home is no longer suitable, that can provide extra care but are alternatives to hospital and residential nursing facilities. Innovative approaches are emerging for those adults and older people who have more complex needs, enabling them to remain in a more homely setting where extra care is provided. Close working between social care, health and housing services is needed to develop such services and there are good examples in Scottish Borders and Midlothian.

Early intervention

We heard from Alzheimer Scotland that a more preventative and early intervention approach to dementia can sustain people in their own homes and communities for a longer period of time and result in a high quality of life for people who might otherwise have been institutionalised. The success of the post diagnostic support service that is provided for one year by professional and highly trained staff is undisputed and helps people recently diagnosed with dementia, along with unpaid carers and families, understand the illness, access supports and services, and to plan for their future – yet this is not implemented across universally across Scotland. Dementia friendly communities have been developed in a number of towns and cities but this too needs to be the norm rather than exception. The efficacy of this strategic approach has been clearly demonstrated through detailed evaluations, including powerful testimony from people with dementia, and their carers and families.

Making better use of adaptations and technology

If our aim, as so often stated in Scotland, is to emphasise supporting people to stay in their own homes and communities for as long as possible, we must do more to improve and adapt those homes to support a better quality of life. Even minor adaptations can deliver significant improvements, particularly when combined with necessary repairs and home improvements, yet we heard that for some people the process of getting adaptations and improvements done is so complex that even professionals struggle to navigate it.

In this context, housing adaptations are often an investment rather than a cost, and we heard that it is helpful if clear arrangements are in place setting out where responsibility sits for paying for and arranging work. Similarly, Technology Enabled Care (TEC) in people's own homes can support greater freedom while also providing greater assurance. However, we know some people are concerned that the introduction of such technology may be used to reduce costs, particularly of overnight support and that reducing face to face support may increase loneliness. It is therefore suggested that the introduction of technology should be explored and discussed thoroughly as part of support planning, where the person's needs, rights and preferences should be paramount.

Involving people and families more in decisions

The need to involve people who use services, their families and carers better and earlier in discussions about social care supports is one of the most consistent themes of this review and we discuss this particularly in Chapter 3 in relation to human rights. In policy terms, much has been written in recent years about the benefits of co‑production and some people report a really positive experience. We heard about a couple of approaches that help support an inclusive approach.

In Falkirk, community-based Living Well centres offer appointments or access to a web portal where people can come in and have a conversation about their wellbeing, and health and social care supports, and access holistic supports, community-based supports and advice to help manage their own health and wellbeing. In Edinburgh, a Three Conversations model is being tried, which focuses on: a) really listening to what matters, so that connections can be made to resources already available in the community; b) understanding what needs to change immediately so that arrangements and a plan are put in place; and c) establishes what support or connections are needed for the person to continue to live their chosen life. This is early work, which is showing positive results at this stage^[32].

The "Esther" approach from Jönköping County Council^[33], in Sweden, is well known internationally, with its focus on delivering the best possible outcomes for a fictional older resident. Creating Esther helped professionals to map a range of care pathways and explore how these could be improved to best meet Esther's needs. A number of areas of Scotland have in recent years tried to take a similar approach, and a National Care Service should build on those examples to ensure a consistent focus in local systems on improvement through the eyes – and experiences – of people using services, their families and carers.

Prevention and community support

The role communities play in supporting adults to remain active in their community simply cannot be overstated. There are many community-led initiatives across the country that provide vital advice and support to adults and unpaid carers, for example through practical peer support, activities and outings. These community supports are often not recognised as part of a care package, but we heard that they can make a tremendous difference to people's quality of life and provide a clear sense of choice and control, including deciding how they spend their time to follow their passions and interests.

Again, there is positive work already underway upon which a National Care Service can build, working in close partnership with Integration Joint Boards, Local Authorities, NHS Boards and other Community Planning partners at a local level. Community supports should not be regarded as an optional add on. Experience during the pandemic has demonstrated just how crucially important community and social connections are to people of all ages and across civic society, and we saw the heroic effort of communities to support people who needed essentials such as food, pharmacy deliveries and socially distanced company. To be sustained, community supports do however need some form of infrastructure and funding – often fairly modest to develop and flourish. There is a network of third sector interfaces that provide a good starting point for this. Community supports are discussed further in Chapter 9.

Social connections are intrinsic to everyone's wellbeing – people who access social care as much as people who do not – and befriending networks can play a significant role in reducing isolation, improving quality of life and providing a gateway to other types of activity. Transport is an important matter for many people as it can inhibit of enable accessibility to a range of support - it was suggested to us that transport should be integrated into the care pathway. Peer support can have a very positive impact, especially for people with mental health problems and people with addictions. The Links Worker Programme^[34], which makes links between people and their communities through their GP practice aims particularly to mitigate the impact of the social determinants of health in people living in areas of high socioeconomic deprivation. There are opportunities, with leadership, investment and focus from a National Care Service, to develop approaches like these more and to support connections that make them more than the sum of their parts.

Marion McArdle and daughter

My eldest daughter Laura is 37 years old and she has profound and multiple learning disabilities and complex health needs which means she needs maximum support with every aspect of her life.

Having a personalised budget has made huge positive changes in Laura's life. She is happier and healthier and she's able to communicate with us much more than she ever did before.

Previously Laura could have up to 42 different people in her life in one week. There was no way these people could get to know her well and so often Laura's limited communication was lost.

Now with Self Directed Support (SDS) Laura employs a small staff team of six people who know her so well and have time to understand what she is trying to communicate.

What a buzz Laura gets when she realises that she has actually controlled a situation by vocalising what she wants!

Before SDS Laura's days were regimented and timetabled to fit in with staff shift times and transport availability. Each morning Laura was washed, dressed and strapped in her wheelchair by 8.30 am regardless of what kind of night she'd had. I could see little chance of her ever reaching her full potential with these limitations.

Now every day is about what suits Laura and she has choice and control over her life and the opportunity to reach her potential.

Despite Laura's significant health problems we hardly ever need to see a doctor or social worker. This must have a huge cost saving. It seems like a win /win situation!

The SDS care package has worked so well, because whilst Laura's needs were being assessed the cost wasn't mentioned. I didn't want to think of Laura's life in terms of money. We got it right for Laura because the focus was always kept on Laura- not the budget!

"What a buzz Laura gets when she realises that she has actually controlled a situation by vocalising what she wants!”

In some parts of Scotland, such as Glasgow and East Ayrshire, community connectors provide a free confidential service to help people access activities, advocacy services, community transport; buddy support and volunteering opportunities. Sometimes these arrangements are embedded within GP practices.

On a similar theme, community brokers across Ayrshire provide information and support to help identify personal outcomes, develop and set up a funded package of support, connecting people to community activities and services. This service is free to the person accessing support: brokers are self-employed, local people who have some personal experience of directing their own support or that of a relative or family member, and now use that experience to help other people. They receive specific training including a new SVQ qualification.

Professionals working together better across traditional boundaries of health, social care support and other services such as housing

We reflect elsewhere in this report on the need for better, faster, more consistent progress with integration of health and social care support. Again, there are areas where progress is really good. The Scottish House of Care Approach^[35] has been widely used and adopted to encourage and promote GP input to care and support planning conversations routine for people with long-term conditions and support self-management – it provides a strong graphic and is easy to remember. In most GP practices across Aberdeenshire, GP-led Virtual Community Ward teams bring health and social care professionals together to identify, coordinate, organise and deliver services required to support people. The team provides short-term integrated solutions within the community as an alternative to more-resource-intensive community and acute hospital admissions. As well as reducing hospital admissions teams have felt a positive impact of the approach in building multi-disciplinary relationships, better use of resource with less duplication, quicker access to interventions and a move to more holistic and person centred care.

Developing the provider network

As well as professionals working together in new and innovative ways, we believe that social care providers should be supported to develop networks of mutual support. The development of alliance based commissioning, provider co-operatives, user-led and community-owned organisational models, and social enterprise models, should be encouraged to help improve quality, flexibility, resilience and responsiveness to people's needs.

All of the above are good examples, but they are not enough. Neither in terms of ambition nor scale are they sufficient to address the challenges adult social care support needs to meet in order to improve the experience of people using it. We believe that a stronger national approach, coupled with local ownership of innovations, is needed to deliver improvements and instil a real learning culture in social care support in Scotland.

Scale-up and spread of innovation is challenging. The idea that new ideas or promising practice can just be 'rolled out' is a fallacy. Large scale implementation of innovation needs leadership, design and contextualisation. Given the current variability in the system, we suggest it is necessary to establish additional national capacity for harvesting ideas and preparing the ground for implementation in a National Centre for Social Care Support Innovation. In this regard, the future role of the Institute for Research and Innovation in Social Services (IRISS) and its inclusion as part of the National Care Service should be considered.

Recommendations

We have identified key priorities to realise, consistently and at scale, Scotland's ambitions to deliver social care services and supports that maximise people's wellbeing and independence:

28. The Scottish Government should carefully consider its policies, for example on discharge arrangements for people leaving hospital, to ensure they support its long held aim of assisting people to stay in their own communities for as long as possible.

29. A national approach to improvement and innovation in social care is needed, to maximise learning opportunities and create a culture of developing, testing, discussing and sharing methods that improve outcomes. The future role of the Institute for Research and Innovation in Social Services (IRISS) and its inclusion as part of the National Care Service must be considered.

30. There must be a relentless focus on involving people who use services, their families and carers in developing new approaches at both a national and local level.

31. Investment in alternative social care support models should prioritise approaches that enable people to stay in their own homes and communities, to maintain and develop rich social connections and to exercise as much autonomy as possible in decisions about their lives. Investment in, or continuance of, models of social care support that do not meet all of these criteria should be a prompt for very careful reflection both by a National Care Service and local agencies.