National Care Service: consultation analysis

4. A National Care Service

Chapter overview

Overall, 72% of respondents who responded to the question on the NCS agreed that Scottish Ministers should be accountable for the delivery of social care, through a National Care Service.

The main themes emerging from the responses to this question related to: the need to avoid adding additional bureaucracy; maintaining local accountability; the role of local authorities; and the challenges faced by rural and remote areas, including the Islands.

A range of other services were suggested for potential inclusion in a NCS, including aspects of housing, education and transport. There were mixed views on whether social care and support in prisons or children's services should be included in the unprompted open-ended responses to this question but a majority (over 70%) were in agreement when these questions were addressed explicitly and quantitatively in the relevant section of the consultation (72% for prisons and 76% for children's services). Further details of the responses to these questions are provided in Chapter 5.

Other cross-cutting themes which emerged throughout the consultation and which are included in this section are:

• The need for more detail on the proposals to inform the debate
• The need for more detail about the costs of designing and implementing an NCS
• Transition risks and centralisation
• The impact on local authority workforces
• Localism and local accountability
• The needs of remote and rural areas
• Human rights and equality issues
• The extent of the proposed NCS
• The delivery of services under the NCS.

Introduction

The establishment of a National Care Service (NCS), accountable to Scottish Ministers, is intended to ensure the Scottish Government can:

• Achieve consistency across the country, and drive national improvements
• Ensure strategic level integration with the NHS that promotes preventative care and reduce the need for hospital stays
• Set clear national standards and terms and conditions for the commissioning and delivery of services
• Bring national oversight and accountability to ensure that all individuals universally have access to the services they need.

Accountability for social care

The consultation asked respondents whether they believed Scottish Ministers should be accountable for social care through a National Care Service (Q20).

Q20. Do you agree that Scottish Ministers should be accountable for the delivery of social care, through a National Care Service?

	Individuals	Organisations
Yes	328 (72%)	148 (72%)
No, current arrangements should remain in place	64 (14%)	29 (14%)
No, another approach should be taken	62 (14%)	28 (14%)
Total	454 (100%)	205 (100%)

Respondents were in favour of this with 328 out of the 454 (72%) individuals that responded to this question and 148 out of the 205 (72%) organisations, in agreement. 90 out of the 660 (14%) that responded to this question opted for another approach with a further 93 out of the 660 respondents (14%) indicating that current arrangements were sufficient.

Amongst individuals, social workers tended to be less likely to agree with the concept of an NCS (with 69 out of 108 social workers (64%) that responded to this question agreeing with an NCS) compared to other groups in particular unpaid carers (164 out of 210 respondents (78%) respondents agreeing) and people accessing care and support (49 out of 65 respondents (75%)). Please note, as previously indicated, these figures are indicative only as one respondent could belong to several different types of stakeholder group so no definitive conclusions can be drawn in relation to subgroups.

Amongst the respondents who contributed via the Easy Read questionnaire, there was a large majority (35 out of the 42 (83%) who responded to this question) who agreed that the Scottish Government should be responsible for the delivery of social care (Q10). When respondents were asked why, there was a theme around consistency of delivery across Scotland and higher standards (removing the "postcode lottery") but also some concerns around political influence and the need for the local delivery of services.

A similar proportion (34 out of the 44 (77%) who responded to this question in the Easy Read format) agreed that 'The need for local delivery of services' should be through a National Care Service (Q11). The reasons given included standardisation across the country and centralised accountability. There were a few comments from respondents that suggested that they believed that a NCS had already been agreed.

There was a general view that the creation of a National Care Service (as has been noted in the previous chapter), would provide the opportunity to remove the perceived postcode lottery of provision across Scotland.

"We believe that the establishment of a National Care Service has the potential to address the gap between promise and implementation and to remove unwarranted disparities between local authorities." (Scottish Human Rights Commission)

In the comments on "another approach should be taken", respondents (369 organisations and individuals) referenced a number of issues with the proposed approach, rather than suggesting alternatives, including: the need to maintain local accountability; the role of local authorities in local accountability; the need to avoid creating too much bureaucracy; the importance of avoiding politicising the service; the need for sufficient funding; the importance of having a deep understanding of the sector; and flexibility for the Islands.

For some stakeholder organisations, the disruption likely to be generated by the creation of a NCS is unlikely to be worth the associated costs:

"The position of GCHSCP is that the proposals put forward in the consultation could largely be achieved without structural change, but by identifying and implementing current areas of best practice, engaging with local services and addressing the identified funding challenges across the health and social care system. Setting up a new NCS will be costly, and there is an argument that this money would be better invested in developing the capacity of local services to work with those on the margins of need and intervening early." (Glasgow City Health and Social Care Partnership)

"The process of integration of care and formation of Integrated Joint Boards was long and difficult and costly in terms of time and resources. We do not believe it is the right time for these services to be subject to further disruption." (Scottish Academy)

In response to this question and throughout the consultation responses, many respondents stated that while they were in support of a National Care Service, time needed to be taken to get it right given the complexity of the issues.

"The NCS is a potentially valuable opportunity for public service improvement. However, if the time is not taken to get it right, it may represent a significant risk to public services. Therefore, we recommend that time is taken over the design of the whole NCS. Time in which detailed discussions about the best next steps for justice and children's services can be carried out in parallel to feed into a full options appraisal considering all the potential options." (Scottish Association of Social Work)

A number of organisations including COSLA and the Scottish Association of Social Work also questioned the timing of the consultation. It stated that it recognised that social care needs to be addressed but, in the current circumstances of the Covid-19 pandemic:

"There is no clear reason why improvement cannot be progressed in the short term through collaborative engagement between the organisations who are currently involved in this space, without embarking on a period of structural reorganisation." (COSLA)

COSLA also stated that much more detail is required in relation to the structure and design of a National Care Service, and highlighted that it could impact significantly on local decision-making, flexibility, choice and ultimately outcomes. These issues are considered in more detail later in this chapter.

Q21 Are there any other services or functions the National Care Service should be responsible for, in addition to those set out in the chapter?

When asked whether there were any other services or functions the National Care Service should be responsible for, in addition to those set out in the chapter on the NCS in the consultation document (Q21), the 351 respondents to this question cited a wide range of services including:

• Occupational therapists
• Education, including education for vulnerable children and young people, and strengthened linkages between education and mental health
• Childminding
• Housing (where it touches on care)
• Transport (where it touches on care, ie. Hospital transport)
• Drugs and addiction services
• Hospices and palliative care services
• Hearing and vision specialists
• Podiatry and chiropodists
• Counselling

Other responsibilities cited included setting standards; standardising training and qualifications; and establishing sufficient and fair pay and terms and conditions for the workforce. Some respondents stated that all care homes should be covered by a NCS and others also questioned the need for private care homes and private provision in general.

The written submission from COSLA questioned the scope of the proposals and the rationale for extending these beyond the recommendations of the IRASC.

"...the scope of the proposals expand significantly beyond what was recommended as part of the IRASC. There is little rationale provided for this expanded scope beyond brief comments made regarding the need for consistency across the system. As has been highlighted in our comments relating to localism, consideration must also be made to the differing needs of people across varying areas in Scotland." (COSLA)

It suggests that removing the statutory responsibility for care services from Local Government would impact on the ability to deliver a joined-up approach. COSLA also notes that the services proposed for inclusion in the NCS have wider linkages with areas such as housing, employability, education, and public safety and protection.

Several respondents also stated that it may be best not to overload a new Service with too many responsibilities. These respondents thought that the Scottish Government should focus on getting the basics of an NCS right first as this is likely to be enough of a challenge. Specific comments here included:

"It would appear that the NCS already wants to take over the world if the whole consultation is to be believed." (Individual respondent)

"The College does not believe that additional responsibilities are required, beyond what is outlined. Some College Fellows are concerned that if anything, the remit is perhaps too large covering multiple areas, and with limited resources available this could spread resource too thinly." (Individual respondent)

"I would limit this first tranche of change to the services looked at in the Feeley Review. I haven't seen any detailed justification for going beyond this. It would enable Ministers to focus on adult care and get it right." (Individual respondent)

"Provision and delivery of the National Care Service is a big enough 'ask' on its own. Let's not over-burden the organisation in addition to what will be an extremely demanding task." (Scottish Veterans Residences)

Q22 Are there any other services or functions the National Care Service should not be responsible for?

There were 300 responses to the question on whether there are any services or functions listed in the chapter that the National Care Service should not be responsible for (Q22). Respondents suggested a range of services including:

• Children's services
• Prisons
• Social work
• Services for non-residents
• Gardening and other maintenance services
• Nursing
• GPs

There was also a large proportion of respondents who stated "no" in response to this open-ended question. Others used the opportunity to state their views on the NCS in general.

There were also some suggestions in response to Q22 that suggested the proposed NCS should follow more closely the recommendations of the Independent Review of Adult Social Care in terms of scope (please see comments above).

The Scottish Trade Union Congress stated that the NCS should be wholly in the public domain:

"To address the core issue and create a truly transformative National Care Service, it must be based on public ownership and control with not-for-profit provision throughout the service." (Scottish Trade Union Congress)

Alzheimer Scotland also suggested that the NCS would provide an opportunity for the Scottish Government to commit fully to implementing the national dementia strategy.

Please note that as this question (Q22) and the preceding question (Q21) on which services or functions should be in or out of the scope of a NCS are open-ended and answered in very different ways, there is no possible direct comparison between the numbers of respondents who suggested a service should be in the NCS and those who suggested a service should be outside the NCS within the scope of this analysis. Further, more quantitative, analysis is provided in relation to the prompted questions on services and functions in the NCS in the following chapter of this report.

Cross-cutting themes

There were a number of cross-cutting themes that emerged from the responses which were not directly addressed by the consultation in explicit questions. As a result, there is no quantitative data that can be attributed to these themes in terms of the strength of the point of view. These issues raised in relation to the general concept of a National Care Service included the following:

• The need for more detail on the proposals in order to inform the debate
• The costs associated with a NCS and how it would be funded
• The existing local authority workforce
• Localism and local accountability
• Human rights and equality issues
• The extent of the NCS
• The delivery of services under the NCS

These are addressed in more detail below. Please note that these cross-cutting themes are indicative only and are not exhaustive. These issues may also be addressed in relation to other questions in the consultation document as some respondents naturally raised the same issue in different contexts. As previously stated, we would encourage interested parties to refer to the full range of published consultation responses for a more detailed discussion of the key issues.

The need for more detail on the proposals in general

Overall, there were a number of comments from respondents on the need for more detail on the proposals in general, and in particular, in relation to the funding of the proposed NCS (please see the following section). As we have already noted, many respondents commented on the difficulty of contributing meaningful comments on the proposals given the lack of detail in the consultation document. Specific concerns related to the timeframe for the consultation and the timing of the exercise in the middle of the Covid-19 pandemic which impacted on the ability of organisations to engage meaningfully with their stakeholders.

Other comments included:

• The need for a direct link to be drawn to the recommendations of the Independent Review of Adult Social Care in Scotland
• Linked to the above, there should be a stronger emphasis on a human rights-based approach to social care, with some suggestion that this approach should be enshrined in legislation
• There should be greater emphasis on the views of people accessing care and support and of people with lived experience
• There was a view amongst some respondents that the consultation document focused primarily on structural changes and less so on cultural change and leadership etc. Some respondents called for greater clarity on where responsibilities will eventually lie.

Several respondents noted that there was a risk that some of the advances in the integration of health and social care over the last number of years could be negatively impacted by the creation of an NCS with some noting that the Integration Joint Boards have only been operational since 2016. There were also some concerns regarding the perceived emphasis on structural change rather than cultural change to focus on person-centred services.

"We are concerned, though, that the consultation paper focuses on organisational restructuring without addressing transformative cultural change which prioritises person-centric services matched to individual's specific needs, broadens definitions of what constitutes care, and encourages feedback and learning through processes of continual improvement." (Frontline care worker)

Several respondents noted that more evidence should be provided to demonstrate the anticipated benefits of the proposed new system to the sector and to the wider Scottish population and some referenced the need for more evidence and research before moving towards a National Care Service.

"The aims of the National Care Service are laudable. However, I am not convinced that these aims can be achieved equitably, sustainably and anti-oppressively via a National Care Service. No evidence has been provided to show that this option has been carefully researched and included all stakeholders in that research." (Current or former frontline care worker and a friend or family member receives or has received support)

The Care Inspectorate, amongst others, also highlighted the need to assess and maintain what is currently working well. This was highlighted in relation to Children's Services by respondents including East Lothian Council and Moray Council Children, Families and Justice Service, with the former noting that Children's Services was not considered in the IRASC and that therefore there was a lack of evidence in this regard. The need for more funding for social care was also raised in this context and is considered in further detail below.

The need for more detail on costs, funding and resourcing an NCS

Linked to the section above, many respondents to the consultation highlighted the lack of any detail around the costs of developing and establishing an NCS and the subsequent impact on their ability to comment on the proposals. Some noted that it was difficult to evaluate the likely impact of the proposals versus the likely impact of maintaining the status quo but with additional funding, in the absence of such information. There was also a view that increasing funding within the current arrangements would avoid the risks of disruptive structural change and would also lead to service improvement.

There were several comments to the effect that the costs associated with the NCS are likely to be significant given the large (and increasing) proportion of the population requiring social care. It was noted that the Independent Review of Adult Social Care estimated that the costs of the NCS were estimated to be £0.66 billion and that there was a noted lack of clarity in the consultation document on how the proposed NCS would be funded.

Some thought that the proposed 25% increase in funding would be insufficient, with a suggestion from some respondents that the system was already stretched after funding cuts in recent years. There was some concern that this additional funding would be absorbed in the setting up of the new structures rather than in supporting frontline care through the provision of services and improving staff pay and conditions. COSLA highlighted that many of the proposals are as yet un costed:

"COSLA and Local Government professional associations are very concerned that the gap between the IRASC's part costing of £660m additional funding (at 2018-19 prices), and the Scottish Government's commitment at a minimum of "over £800 million more by 2026-27", is far too small to cover all of the un-costed recommendations. Unless significantly extended beyond this "minimum", it would not provide sufficient funding for paying fair wages to social care workers, let alone increased rights and support for unpaid carers, reform or abolition of eligibility criteria, the increased demand from the removal of care charges, implementing "ethical" and "collaborative" commissioning and procurement, improved data and information technologies, potential VAT and other costs." (COSLA)

COSLA estimates that the full implementation costs will be in the region of £1.5 billion. For some respondents, there is a need to provide modelling of likely demand for the services outlined and how the NCS will keep pace with the demand in light of changing demographics and in particular an ageing population. Some respondents also stated that the benefits to local populations versus the impact of increased costs are unclear. Other issues cited included:

• The likelihood of increased costs due to an ageing population
• The need for more detail around the financial structure of the proposed NCS, including its financial powers, governance and decision-making structures
• The need for more detail on the costs of the operational commitments in the consultation document, and whether these will be funded by the Scottish Government
• A consideration of the investment required for a person-centred or human rights based approach is needed alongside an evaluation of the funding that is likely to be available
• The need for a medium- to long-term financial strategy for the NCS and for social care
• The need for a more innovative approach rather than a focus on eligibility criteria
• Whether there is sufficient staff working in the sector to meet the perceived high levels of demand for social care in Scotland
• The need to model the impact on the local government grant settlement
• The direct financial implications of extending eligibility and entitlement to services

Transition risks and centralisation

There were also some concerns about the disruption that is likely to occur given the magnitude of the changes and the need to maintain appropriate levels of service to users during the transition period. There were also concerns, as previously noted, that this disruption and "upward cost drift" would offset any potential service improvements. Several respondents noted that lessons learned from other centralisation initiatives, such as that of Police Scotland, should be taken into consideration. As we have previously noted, some respondents also stated that if the funding for the new NCS was diverted into improving existing provision there would be a positive impact on care outcomes.

"The introduction of a new National Care Service will absorb energy, money and cause huge planning blight for years – especially given that recovery from the pandemic is the priority." (Shetland Public Protection Committee)

The existing local authority workforce

The likely impact on the finances and staffing of local authorities was also raised as an issue. COSLA and other local authority representatives amongst others noted the complexity of the contracting arrangements with social care staff and the need for TUPE protection for existing staff. There was also a perceived risk that the potential disruption and uncertainty could lead to staff leaving the service.

"The sheer scale of TUPE arrangements that would need to be undertaken requires independent discussion." (COSLA)

"SASW members raise concerns around the prospect of moving employers, TUPE and pension impacts. They also want to ensure that, should there be any movement, social worker posts are protected in number or increased to take on more preventative work. There must be enough resources to meet the needs of the communities served." (Scottish Association of Social Work)

COSLA also highlighted that the document does not address the employment status of NHS staff who work in health and social care or those working in the third sector. Other employment issues are considered later in this report but one issue that should be noted in this context was raised by several respondents i.e. the lack of mention of the role of the Chief Social Work Officer in the consultation document.

Localism and local accountability

Concerns were raised by many respondents about the loss of local accountability under a more centralised system. There were also concerns that an overly centralised approach would work against a person-based, human rights based approach to service provision and effective responses to local needs. Many respondents highlighted the importance of protecting and maintaining existing local initiatives and programmes that were working well. At the same time, as we have noted, many respondents wanted more consistent standards and an end to the "postcode lottery".

"The loss of local accountability in the system. Local accountability of public services is extremely important for citizens and services alike. These proposals will structurally undermine localism." (Individual respondent)

"We…do not wish to undo the examples of strong integrated working arrangements in many localities through the implementation of the new NCS. We are proud of the SLT leaders in our membership who have worked within their local structures to develop effective and innovative delivery of care to their communities. We would hope a National Care Service would allow for the continuity of local accountability, set within the context of community planning." (The Royal College of Speech and Language Therapists)

"South Ayrshire HSCP is close to its community (and works closely with the Council and Community Planning Partnership in this regard) and values its Locality Planning Groups. These constructs and the general principle of localism should not be lost or overlooked in the development of a 'national' service." (South Ayrshire HSCP)

The needs of remote and rural areas

The importance of understanding and respecting the specific and unique needs of remote and rural areas, and in particular the Islands, was highlighted by many respondents, including in individual Council submissions, the relevant engagement events and by COSLA.

"The danger is that they will ignore the special problems faced by those in the Highlands & Islands area." (Person accessing care and support)

"Scotland is unique with varying demography, epidemiology, morbidity and mortality. Rural and urban needs are unique too e.g. cities v remote island communities therefore 'one size' cannot meet all needs; however these unique needs should be 'fed' into the bigger picture with commissioning and procurement." (Person accessing care and support)

"The centralised approach does not suit all and will certainly not suit islanders." (Unpaid carer)

The need for an impact assessment for these areas was emphasised by several respondents. The Orkney Integration Joint Board, for example, welcomed the Government's commitment to undertake an Islands Impact Assessment prior to the drafting of the legislation as a way of giving more time for consideration of the issues.

"We believe that for this to work most effectively, locally elected representatives should maintain accountability for the delivery of social work and social care services. As a remote and rural island community, the transfer of this accountability to Scottish Ministers runs the risk of being perceived by our local communities as very distant and removed… we strongly advocate for people to benefit from decisions taken locally and for those taking those decisions to be accountable locally… The timescale for response to the consultation has been tight, and the breadth of proposals contained therein has made it difficult for us to fully consider where there may be implications for an Islands Authority such as Orkney. Time for further thinking on this, particularly as more detail is developed in relation to the proposals, will be welcome, and the Islands Impact Assessment will provide a vehicle for this." (Orkney Island Council)

"Given the maturity of integration arrangements in a number of island settings, as well as the importance of established local democratic arrangements in islands more generally, it is our contention that an islands impact assessment is required prior to any proposals being progressed, and certainly before they are finalised." (COSLA)

Respondents also raised a number of issues and potential risks of centralisation including remote management structures and travel times for vulnerable groups in rural and remote areas if services and support are not available locally.

Human rights and equality issues

Human rights and equality issues were raised throughout the consultation. Overall, respondents emphasised the need to focus on a human rights or person-centred approach. There was also a clear view that there should be a commitment to placing people with lived experience of social care at the heart of all processes associated with the design, governance and monitoring of provision. Many respondents highlighted that this should be done in a meaningful way, warning of the risk that this might be seen as a tick box exercise.

"To ensure those with lived experience of social care are central to the governance, provision and monitoring of social care at all levels of the NCS." (Person accessing care and support)

"Members of the CHSCA should meet members of the public, those with lived experience, and their workforce outside regular meetings, to listen and expedite concerns. These should be in informal settings.' (Person accessing care and support)

We have noted above that some respondents contrasted a rights-based approach to support at a local level with the desire for standardisation. Other respondents highlighted specific rights issues in provision.

"There is a real and substantial opportunity for the Scottish Government arising out of the approach to be taken and definition of "complex care needs" developed and delivered by a new NCS. The proportion of complex cases like my son's, is relatively small but due to the challenges and expertise required, many of these care packages have to be outsourced to specialist providers in England. The only provision in Scotland has been secure psychiatric adult hospitals in Scotland, not set up or appropriate for the provision of person-centred holistic care and community involvement of adolescents and younger adults. Commissioning services in England is expensive… it also moves service users far from their family home, against their human rights for a family life." (A friend or family member of mine receives, or has received, social care or support)

Other rights-based comments referenced:

• Support for service users and carers in seeking judicial reviews, including advocacy and legal aid
• The implications of data sharing and the importance of respecting the rights of people accessing care and support

The issue of the need for parity between social work and health was also raised in relation to a rights-based approach.

"We are concerned that the voice of Social Work will be marginal to that of Health in central Government; and we are concerned that the clamour for delayed hospital discharge will drown out our capacity to work in rights-based and relationship-based ways with people." (Social Work and Social Care Advisory Committee: NHS Highland)

The issue of gender was raised by a number of respondents, with comments around the composition of the social care workforce and the impact that investment in the sector would have on women. The fact that most unpaid carers are female was also highlighted:

"The issue of gender is a crucial consideration for the development of the NCS… Only a robust gendered approach will ensure improved outcomes are proportionately considered in terms of women's needs. This needs to be underpinned by the evidence that explains how women face inequalities and, in some cases, disadvantages because they are women." (COSLA)

Greater integration between domestic abuse services and other services was also referenced. The Scottish Women's Convention emphasised that women want to see that lived experiences of mental health are taken into consideration in the design and planning of services to assist in better understanding of their needs.

"It all depends on what your condition is. It could be anxiety and you'll talk to everyone, and you'll blurt it out, but someone who has depression may not be quite so open… You may be okay to talk one day, but if they're then phoning you back the next day, you may not want to talk… and if you can't take the call, you're put to the bottom of the list again." (Scottish Women's Convention)

Other issues raised by the Convention include:

• The importance of understanding the needs of specific communities such as the Asian community where counselling and mental health support can be challenging due to cultural taboos and a lack of multilingual counselling
• The importance of understanding and respecting the needs of older women

"A lot of older women shared that they have been belittled by health and care professionals because of their gender and are routinely told "it's just your age" or "it's just your menopause" as a way of denying them the support and medical intervention they need." (Scottish Women's Convention)

The LGBT Health and Wellbeing organisation stated that the inclusion of minority groups should be embedded from the start.

"Rather than, as currently happens, equality and diversity work largely being seen as an optional add on for providers, instead of as core business." (LGBT Health and Wellbeing)

LGBT Health and Wellbeing highlighted that some lesbian, gay, bisexual or transgender (LGBT) people experience barriers to accessing care, and have poorer experience of care when compared to non-LGBT peers and that most health and social care services do not collect sexual orientation or gender identity data and do not measure either uptake or service satisfaction levels for LGBT people, which hinders understanding of their needs:

"For example, there is evidence that public authorities do not always properly understand the needs of older LGBT people in care homes, and are failing to provide safe and culturally sensitive care and support." (LGBT Health and Wellbeing)

The extent of the NCS

While the scope of the NCS is considered in more detail in the following section (in relation to the consultation questions), there were a number of issues raised in general and unprompted in relation to the scope of the NCS in this section of the consultation on the creation of a NCS. These comments should be considered in conjunction with the more quantitative analysis in the following chapter.

For some respondents, there was little differentiation between the roles of social care and social work, and some thought that some areas of social care provision were not detailed or addressed in the consultation. Examples given included: Adult Support and Protection, Children's hearings and adoption and fostering and unscheduled care.

Several respondents raised the issue of social housing. There were some concerns that housing was not addressed as part of the consultation, particularly given the stated ambition of keeping people within their own homes.

A number of respondents suggested that this is a considerable oversight, given the importance of supported housing. Some respondents highlighted the need for alignment between the proposed NCS and housing services and initiatives, including Housing to 2040 and Ending Homelessness Together. The importance of joined up multidisciplinary working was mentioned in this regard by several respondents. Partnership working, particularly in relation to dealing with people with complex needs, was seen as crucial to maintaining people accessing care and support's health and wellbeing.

One respondent highlighted the importance of engagement with the Housing Division, the Scottish Federation of Housing Associations (SFHA), the Chartered Institute of Housing (CIH) and Registered Social Landlords (RSLs) amongst others. If housing is to be included in any NCS, some thought that the costs of this should be made clear. The importance of housing services in relation to preventative care was also highlighted.

"It would be good to see a stronger vision for the partnership role of housing and particularly social housing within the proposed Community Health and Social Care Service. There needs to be greater recognition of the contribution of housing and housing support in preventing people from reaching crisis point and entering formal care / hospital." (Queens Cross Housing Association).

Other issues raised included:

• The ownership of current accommodation and how this might change under the proposals
• The importance of good quality housing services and social housing providers in reducing costs to the health sector

Community transport was also raised as a service that should potentially be in the scope of the NCS.

"Community Transport plays a critical role in supporting independent living and tackling exclusion, isolation and loneliness for people and communities across Scotland. The sector should be a priority for the new National Care Service in order to achieve the ambitions of the Christie Commission, which identified back in 2011 the need for public services to 'focus on prevention and early intervention' by tackling 'root causes', reducing inequalities and minimising the long-term growth in demand in the face of our ageing demographics." (Community Transport Association)

The delivery of services under the NCS

There was a view that the consultation document did not adequately reflect the fact that the majority of services are provided by the third and private sectors. There was also a view that a national job evaluation scheme would be challenging, particularly around the opt in from these sectors and the differences in pay and conditions. Enforcement was also seen as an issue. There were also some concerns around the role of the third sector and in particular whether the proposals would impact or exacerbate the perceived existing inequality between the third sector and statutory services:

"The key message that came through our discussions was the importance of valuing the third sector and understanding the expertise of staff and the specialist nature of third sector organisations. The third sector must be viewed as equal partners to statutory partners with access to long-term, sustainable and adequate funding to enable them to continue to play their vital role in the delivery of social care support." (Coalition of Carers in Scotland)

Other issues raised included the importance of the third sector in the delivery of children's services in Scotland and the need to include these groups explicitly in the consultation through meaningful engagement.

"There needs to be more uniformity in what people and carers can expect and that there is clarity about what services are available. The third sector has a major role to play in supporting people and their families. There is a need to provide parity across sectors - no one discipline holds the key to a person's recovery and wellbeing - it takes a team of people and their families/networks to support the person who is unwell or having difficulties." (Unpaid carer)

There was also some uncertainty about the role of local authorities in service delivery in the future under the proposed arrangements. Overall, however, there was general support for a National Care Service in the quantitative responses from both individuals and organisations, but there were concerns around the lack of detail in the consultation document particularly around funding and costs, and the speed of implementation and consequent likely disruption to the existing system.