Adult social care: independent review

Chapter 6 A National Care Service for Scotland – how it should work

"We must shift beyond the mindset of existing systems and services to embrace individual and community capacities, and collaborative opportunities to enable innovative support mechanisms.”

The importance of integrating health and social care is as important today as it was in 2012 when the Scottish Government consulted on proposals that were given effect by the Scottish Parliament through the Public Bodies (Joint Working) (Scotland) Act 2014.

Progress has been patchy. In particular it is evident that the ambition quoted above – that whether money for support and services is from an "NHS budget" or a "Local Authority budget" should be of no importance to the person using services – has not been achieved. This is not merely an accounting problem. It is a significant impediment to the wellbeing of people who use health and social care support services, because it gets in the way of early intervention and preventative approaches, and it is a significant barrier to innovation for people working in health and social care support.

This chapter builds on the principles set out in Chapter 5. We have included quite a lot of detail about structures in this chapter, to help people who currently work in health and social care organisations understand the changes we are suggesting.

We are concerned that, by setting out this detail, we may give the unintended impression that we believe structural change is what matters most. We do not. In some ways we would prefer not to have to recommend any structural change at all. All structural change involves effort, and money, which some people will argue would be better used in supporting people. We do not disagree. But structural change is necessary if the structures themselves are impeding good care and support for people, which we believe is currently the case.

The changes we propose here would likely not be necessary if more progress had been made by the Scottish Government, Health Boards, Local Authorities and Integration Joint Boards with integrating health and social care. Wishing it were so does not make it true, however. We therefore encourage everyone involved to embrace these proposals as they are intended to be received: as a means through which to achieve consistent, Scotland-wide improvements in social care supports focused entirely on improving outcomes for people using and working in social care, and to the potentially enormous benefit of civic life and local communities. We have been asked for clarity on responsibilities; for obstacles to be removed to good, rapid decision making; for arrangements to be made to enable good ideas to be shared, spread and deployed easily; and for changes that will enable money to flow easily to where it can be used to best effect. We have framed the recommendations that follow around these basic, reasonable, requests. It should not be beyond our collective means in Scotland to achieve them.

Statutory basis for a National Care Service

To address the problems we have already outlined, and for the reasons we set out in Chapter 5, we recommend that new legislation should empower Scottish Ministers to:

• Discharge responsibility for the local planning, commissioning and procurement of social care support via Integration Joint Boards; and
• Create national bodies to service and support social care support and social work at local and national level.

Ministers should be able to change the number and configuration of Integration Joint Boards and national care bodies without changing primary legislation. This approach mirrors the existing powers of Ministers to establish NHS territorial and special boards.

Some existing agencies should become national care bodies under the National Care Service: the Care Inspectorate and Scottish Social Services Council. We recognise that the remit of each of these agencies extends beyond adult social care but believe their inclusion will be vital in establishing a coherent context for the National Care Service. We also consider that this will provide additional impetus for close working between adults, children's and criminal justice social work services, whatever the conclusion made about overall structures.

Within the National Care Service, provision will also be needed to oversee priorities that currently have no home in the national infrastructure, such as workforce planning and development, data and research, IT and, as appropriate, national and regional service planning, and to manage services that are better organised on a once-for-Scotland basis, such as support for people with complex and specialist needs, provision in custodial settings including prisons, and so on.

The remit of this review is only to consider adult social care. As part of our work we have engaged closely with colleagues leading on The Promise, which is responsible for driving the work of change demanded by the findings of the Independent Care Review for children's care^[28]. The recommendation of our review is that social work and social care support should be made more cohesive across age and professional groupings, should enable transitions between children's services and adult services, and that further work should be done to ensure that implementation of the two reports is mutually reinforcing. This will need close attention during implementation.

Sophie Hogg

I am 74 years old and was diagnosed with vascular dementia a couple of years ago. I thought I'd been asked to go to the clinic to get help with my diabetes when I was given the news. The doctor told me I had dementia, handed me a DVD and a book and opened the door for me to leave. Within the space of a few minutes I had been told I wouldn't be able to drive again and I'd need to get a power of attorney. It was a dreadful way to be given a diagnosis. I thought my life was nearing an end, I even started to clear out my house and give my jewellery away to my family. However, since then I have been very lucky with the support I've had. I was referred to Alzheimer Scotland and given a great link worker. I am able to live a great life because I have support and have been put in touch with other people in the same position. My husband Robert and I regularly volunteer, helping people with special needs. I am living a full life, but there are still too many other people who aren't getting the support I'm getting and are suffering as a result.

"I am living a full life, but there are still too many other people who aren’t getting the support I’m getting and are suffering as a result.”

Marian Garcia
Link Worker

Sophie is a fine example of someone who has learned how to live well with dementia. Her confidence has grown exponentially, having gone from not attending groups to now contributing, supporting her peers, campaigning and helping others with a recent diagnosis. Sophie self-manages very well. She knows the strategies she needs to cope, and she knows physical health is good for her mental health. Before COVID, Sophie had a regular gym and swimming routine. She lost a lot of weight and reported feeling empowered and confident. Without Post Diagnostic Support, I believe we'd be seeing a very different Sophie today. She is an inspiration.

"Sophie self-manages very well. She knows the strategies she needs to cope, and she knows physical health is good for her mental health.”

Governance of a National Care Service

The National Care Service should have a board of governance with a Chair appointed by, and accountable to, Ministers. Its other members must include representation of the workforce, people experiencing social care support, unpaid carers and providers.

The National Care Service should have a Chief Executive who is the accountable officer to the National Care Service national board of governance and is also a member of the Scottish Government Health and Social Care Management Board, as the Chief Executive of NHS Scotland is now. The Chief Executive of NHS Scotland should be a member of the board of the National Care Service. If there is a similar board for NHS Scotland then the Chief Executive of the National Care Service should be a member of it.

Functions of a National Care Service

The National Care Service should:

• Provide assurance to Ministers and to the public about the quality of social care support in Scotland and ensure that opportunities for continuous improvement are identified and implemented.
• Oversee the work of reformed Integration Joint Boards and national care bodies and ensure effective engagement is taking place at all levels.
• Establish, maintain and oversee national requirements for ethical and collaborative local commissioning and procurement of social care (see Chapter 9). These requirements will cover standards of care and outcomes to be achieved, and fair work.
• Develop and maintain the distribution formula for direct allocation of budgets by the Scottish Government to Integration Joint Boards and national care bodies.
• Be responsible for social care support functions that currently have no home in the national infrastructure, such as workforce planning and development, data and research, IT and, as appropriate, national and regional service planning, and to manage services that are better organised on a once-for-Scotland basis, such as support for people with complex and specialist needs, provision in custodial settings including prisons, and so on.
• Ensure effective working with NHS Scotland, establishing a joint approach where beneficial to people accessing care. This priority could be enabled by the creation of a similar board of governance for NHS Scotland and the creation of a National Integration Joint Board where the senior leadership of the National Care Service and NHS meet regularly to agree strategy and priorities.
• Ensure effective local and national working with other public services including transport, housing and education, all of which are key to public health and wellbeing. People's environments can be disabling if not properly planned for accessibility, and people's needs for care and support vary depending on their context. More broadly than social care and health, it is important that the public sector as a whole designs different environments – home, workplace, local services and infrastructure (e.g. transport, amenities), community networks – to support people's independence and enable everyone to participate as full citizens in society.

Monitoring progress

As part of its oversight of local and national progress the National Care Service will need to develop and maintain outcome measures for the Integration Joint Boards and national care bodies, and monitor their performance.

Previous attempts to establish a single set of outcome measures across adult health and social care have been hampered by complexity and duplication. These obstacles need to be overcome to ensure clarity of purpose and transparency of the evidence base for progress. We recommend that a single, clear set of outcomes, process measures and balancing measures should be developed for the whole health and social care system. This should involve people using social care support, patients, unpaid carers, providers, clinicians and professionals, to ensure the right balance of measures is identified. This should be developed as a priority and should simplify, reduce in number and improve the current range of measures. It should acknowledge this report and ensure a focus on outcomes for people using social care supports and healthcare services and should reflect the ethical and collaborative approach to commissioning that we recommend here.

Reforming Integration Joint Boards

The law should be changed so that Integration Joint Boards are reconfigured to employ staff, hold assets and contracts, including the GMS contract and employment of directly employed independent contractors in health, as described in Chapter 5.

Integration Joint Boards should contract directly with public sector providers, and with the third and independent sectors. This means that the National Care Service, through Integration Joint Boards, will hold contracts with providers of social care support services, which is an arrangement not unlike the contractual arrangements between NHS Boards and primary care contractors such as GPs and pharmacists. Consideration should be given to whether any contractual arrangement is needed with Local Authorities for the provision of professional social work services and how this would work.

The post of Integration Joint Board Chief Officer should be retained though the skillset for the job should be updated, clarified and sharpened to reflect the new responsibilities of Integration Joint Boards. Currently Chief Officers perform a dual role as accountable officer for the strategic commissioning plan and use of the integrated budget to the Integration Joint Board, and as director of integrated delivery within the Health Board and the Local Authority. Under the new model Chief Officers, and the staff who plan, commission and procure care and support, as well consideration given to other key staff such as Chief Finance Officers, should be employed by the Integration Joint Board itself, rather than by the Local Authority or Health Board as is the case now. They will no longer be jointly accountable to Chief Executives of Local Authorities and Health Boards.

We heard and saw compelling evidence of where current integrated arrangements were working well under Integration Joint Boards and their delivery arm, Health and Social Care Partnerships. This was especially the case where all social care, social work and community based healthcare were delegated to its greatest extent. We strongly believe that there is scope to be more consistent in these arrangements and embed the effective working we saw throughout the country. We are also keen to ensure a further narrowing of the gap between purchaser and provider, an unwelcome split introduced to social care and social work some 30 years ago. We intend this as a means by which the best possible outcomes are planned for and achieved, and high quality integrated services are delivered across Scotland.

Integration Joint Boards should continue to develop strategic commissioning plans, and should be given direct responsibility for procurement, holding contracts and contract monitoring. Strategic commissioning plans must be better linked to planning for other types of service, including particularly housing plans and plans for acute hospital care.

The Integration Joint Board (equal numbers of elected members and NHS non executives) and Integration Joint Board Strategic Planning Group (a broad range of representative user and professional interests) should be combined to form the membership of the reformed Integration Joint Board.

Every member of the Integration Joint Board should have a vote. Membership should include but not be limited to representation of the workforce, people who use services, carers, providers, professionals, localities and local communities. Careful thought will need to be given to the workable size of Integration Joint Board and appropriate support will need to be provided to enable participants to fulfil their responsibilities. We know from experience with integration that very large Boards are unwieldy, but that at the same time narrow membership seems to inhibit innovation and a local sense of ownership, and the clear sense of involvement that gets things done. This combined with active community engagement and involvement will provide a powerful basis for planning and delivering change and improvements at a local level. Additional support and training for members and Chairs of reformed Integration Joint Boards would help them to fulfil their functions more effectively without resorting to simplistic solutions to these challenges.

The Integration Joint Board budget should continue to include a sum for unplanned adult hospital care to help incentivise preventative interventions. Integration Joint Boards should bear responsibility for unplanned and potentially avoidable hospital care.

Integration Joint Boards' budgets should be allocated directly by the Scottish Government, rather than via Health Boards and Local Authorities as at present, as set out in Chapter 5. See Chapter 11 for financial recommendations.

Recommendations

We recommend the following arrangements should underpin a National Care Service:

21. The National Care Service in close co-operation with the National Health Service should establish a simplified set of outcome measures to measure progress in health and social care support, through which to oversee delivery of social care in local systems via reformed Integration Joint Boards and national care bodies.

22. A Chief Executive should be appointed to the National Care Service, equivalent to the Chief Executive of the National Health Service and accountable to Ministers.

23. Integration Joint Boards should be reformed to take responsibility for planning, commissioning and procurement and should employ Chief Officers and relevant other staff. They should be funded directly by the Scottish Government.

24. The role of existing national care and support bodies – such as the Care Inspectorate and Scottish Social Services Council – should be revisited to ensure they are fit for purpose in a new system.

25. The National Care Service should address gaps in national provision for social care and social work in relation to workforce planning and development, data and research, IT and, as appropriate, national and regional service planning.

26. The National Care Service should manage provision of care for people whose care needs are particularly complex and specialist, and should be responsible for planning and delivery of care in custodial settings, including prisons.