National Care Service: consultation analysis

5. Scope of the National Care Service

Chapter overview

This section of the report considers respondents' views on the services that should fall under the remit of a National Care Service.

Children's services

Overall, the majority of respondents (396 of 521 (76%)) agreed that Children's Services should be included in a National Care Service (NCS). Three quarters of individuals who responded to this question and a similar proportion of organisations were in agreement. A number of key stakeholders however did express concerns about the proposals with several suggesting that more evidence on the likely benefits of the proposals is required, including, as previously noted, some of the local authorities. There were a number of risks identified here by individuals and organisations, including the potential loss of a local dimension to responding to need and the potential loss of the link to education.

Healthcare

Around 70% (380 out of the 544 respondents to this question) agreed that the proposed NCS and the Community Health and Social Care Boards (CHSCBs) should commission, procure and manage community health care services. The main reasons given in support of the proposals related to a more streamlined and consistent service and improved accessibility for people accessing care and support. Reasons given by those who disagreed with the proposals included the availability of funding and perceptions of the existing relationships between health and social care. The most frequently cited benefit of CHSCBs managing GPs' contractual arrangements was "better integration of health and social care". This was followed by "improved multidisciplinary team working". The most frequently cited risk was "unclear leadership and accountability requirements". This was followed by "fragmentation of health services".

Social work and social care

The most frequently cited benefit of social work planning, assessment, commissioning and accountability being located within the NCS, was "more consistent delivery of services". This was followed by "better outcomes for service users and their families". Risks identified included a loss of local understanding, the potential loss of accountability, and the risk that social work would be overshadowed by other services.

Nursing

A majority agreed with the proposed leadership role of Executive Nurse Directors (234 of 436 (54%) said yes without qualification) and that the NCS should have responsibility for overseeing and ensuring consistency of access to education and the professional development of social care nursing staff, standards of care and governance of nursing with almost two thirds in agreement. There was also strong agreement with the proposal that Executive Nurse Directors should have a role in the proposed Community Health and Social Care Boards.

Justice social work

Nearly two thirds agreed that Justice Social Work should be included within the remit of the NCS (241 of 388 respondents (62%)). Reasons given included the need to keep all forms of social work together and the fact that offending behaviour is often linked to other care needs. Those who disagreed tended to say that the proposed NCS is too large and centralised and that there is a need to reflect local requirements. The main benefit was thought to be "more consistent delivery of justice social work services". Around half of respondents to the question on risks selected: less efficient use of resources; worse outcomes for people accessing care and support; poorer delivery of services; and weaker leadership of justice social work.

Prisons

A majority of respondents (233 of 324 respondents (72%)) also agreed that responsibility for social care services in prisons should be given to a National Care Service. Reasons given included better support for prisoners with mental health problems or learning disabilities and smoother transitions at the point of release, amongst others.

Alcohol and drug services

A majority also agreed that Alcohol and Drug Partnerships would have the benefits of providing greater coordination of Alcohol and Drug Services (267 of 328 respondents (81%)) and better outcomes for people accessing care and support (248 of 328 respondents (75%). Confused leadership and accountability was viewed as the main drawback of the Partnerships. Three quarters agreed that they should be integrated into the CHSCBs. Eight in ten agreed that residential rehabilitation services could be better delivered through national commissioning.

Mental health services

Around three quarters of respondents agreed that the list of mental health services provided in the consultation document should be incorporated into a NCS. In response to the question on how best to link the mental health care elements into a NCS, suggestions included: quicker referrals; the use of multi-disciplinary teams; and better sharing of information across services.

National Social Work Agency

There was a general agreement around the potential benefits of a National Social Work Agency that were outlined in the consultation document: improving training and continuous professional development; supporting workforce planning; and raising the status of social work. Two thirds agreed that the proposed Agency should be part of a NCS. Around 80% thought the Agency should have a leadership role in relation to social work improvement, social work education; and a national framework for training and development.

Introduction

This section of the report considers responses in relation to the scope of the National Care Service. It encompasses: children's services; healthcare; social work and social care; nursing; justice social work; prisons; alcohol and drug services; mental health services; and a National Social Work Agency.

Nearly two thirds of respondents to the Easy Read questionnaire agreed at "Question 12: Do you agree all the areas should be in the National Care Service?". This equates to 26 of the 40 respondents to this question (63%). Nine (23%) had no preference and five (13%) said "no".

Children's services

There were 521 responses to the question on whether the NCS should include both adults and children's social work and social care services (Q23a). The majority of individuals (281 out of the 373 (75%) who responded to this question) and organisations (114 out of the 147 (78%) who responded to this question) agreed that it should. There were 440 comments on this question. For those that agreed, commonly cited reasons were:

• An alignment with a "cradle to grave" approach
• It would help ease the transition between children's services and adult services - and create a more joined up approach
• Greater standardisation across Scotland

For those that disagreed, reasons include the alignment between education and health and a desire not to introduce too much complexity. There was also broad agreement from both individuals and organisations that locating children's services within the NCS would reduce complexity for children in a number of key groups.

Some stakeholders disagreed quite strongly with this proposal, in some cases because of the lack of detail behind it. There were some comments for example on the binary nature of some of the questions. Social Work Scotland, for example, stated:

"This is too complicated a question to simply provide a 'yes' or 'no' answer. The implications of either response are profound; not just for social work, but for children's services as a whole. We accept that there is no status quo option… change is guaranteed for every local authority in Scotland… The question is therefore whether these specific proposals represent reform likely to provide social work and its partners with an enabling context within which to affect meaningful, positive, sustainable change for children and families... As the Promise Scotland has framed it: will it help us keep the Promise?" (Social Work Scotland)

The Promise, the Care Inspectorate and others highlighted the need for more evidence in relation to this proposal:

"We have not seen evidence that bringing children's services into a National Care Service developed in response to an adult social care review will address difficulties in the system. It is not clear that children and families experience better outcomes in areas of the country where children's services are the responsibility of an integration authority rather than a local authority." (Care Inspectorate)

Both SOLACE and COSLA did not agree with the inclusion of Children's Services within an NCS.

"COSLA is clear that Children's Services, including the social work workforce, should remain within Local Government. The inclusion of children's services within the National Care Service consultation goes beyond the scope of the Independent Review of Adult Social Care. It is a significant concern that the proposals in the consultation have been brought forward without any scoping, discussion and crucially without seeking the views of children and young people, their families or indeed those working with them." (COSLA)

COSLA emphasised that there should be consultation with children and young people on these aspects of the consultation proposals. The Alliance and Barnardo's Scotland also suggested that children and young people should be consulted on the proposals and that communications should be tailored to their needs and preferences so that they can be involved in a meaningful way.

Children in Scotland amongst others highlighted the complexity of the issues associated with moving Children's Services to the National Care Service and stated that the sector would benefit from additional evidence and consultation.

"Many of Children in Scotland's members we spoke to did not feel they had sufficient time to fully engage with and consider the proposals within the National Care Service consultation. The consultation document is 137 pages and covers a wide range of care services that link to many areas of children's and families' lives. The proposals to restructure the current social work and social care system are complex and may have significant unintended consequences. We believe the children's sector would benefit from additional time to consider the proposals, review additional evidence, talk with colleagues from different organisations and sectors, and discuss the proposals with civil servants." (Children in Scotland)

Q24. Do you think that locating children's social work and social care services within the National Care Service will reduce complexity for children and their families in accessing services?

	Individuals		Organisations
	Yes	No	Yes	No
For children with disabilities (478)	238 (68%)	114 (32%)	86 (69%)	39 (31%)
For transitions to adulthood (495)	268 (75%)	91 (25%)	105 (77%)	30 (22%)
For children with family members needing support (467)	246 (71%)	100 (29%)	89 (74%)	31 (26%)

Approximately 350 individuals and 120 organisations responded to the three statements in Q24 on whether locating children's social work and social care within the National Care Service will reduce complexity in accessing services.

Overall, 325 out of the 478 (68%) that responded to this question agreed that locating children's social work for children with disabilities within a National Care Service would reduce complexity. There were 353 respondents who gave a reason for their response to this question. Common reasons given included:

• A single point of access for families and carers
• Greater standardisation and consistency across Scotland
• Smoother transitions from children's services to adult social care
• More or better support for families
• The importance of multidisciplinary working
• The potential for data sharing

There were 342 respondents who gave a reason for their response at Q24b in relation to the transition to adulthood. Respondents who agreed provided the following reasons:

• A more seamless transition
• A reduction in complexity and therefore frustration and stress for families
• More support for young people's mental health
• A more joined up approach for families
• Better communication and data sharing between service providers

There were 300 respondents who gave a reason for their response at Q24c. For children with family members needing support, a whole family approach under an NCS would be welcomed alongside greater consistency across Scotland. Other reasons provided included clear service levels and standards and better information sharing.

People accessing care and support tended to be more positive about each of the three statements in the table above in relation to Children's Services and social workers less so. Overall, social workers were less positive about each statement compared to other respondent groups (for children with disabilities 54 out of the 111 respondents (49%), for transitions to adulthood 62 out of the 112 respondents (55%), for children with family members needing support, 55 out of the 107 respondents (51%) responding with 'yes' to this question.

Q25 Do you think that locating children's social work services within the National Care Service will improve alignment with community child health services including primary care, and paediatric health services?

Of the 466 people who responded to Q25a on whether this would improve alignment with community child health services including primary care, and paediatric health services, individuals and organisations were in broad agreement with 230 out of the 345 (67%) individuals and 77 out of the 120 (64%) organisations saying yes. There were 346 respondents who gave a reason for their response at Q25. These reasons commonly included:

• The system is perceived as disjointed at the moment
• It would create more consistency and standardisation
• It would help communication and data sharing
• It would help with referrals and transitions

A lower proportion of social workers who responded to this question agreed that locating children's social work services within the National Care Service would improve alignment with community child health services with 46% of them agreeing with this proposal.

Overall, those that disagreed tended to reference cultural and structural differences between health and social care. There were 132 comments from respondents that disagreed with this proposal. These included:

"They are distinct and different services with different standards, values, principles, functions etc." (A friend of family member of mine receives, or has received care)

"There are different values for professionals, different attitudes to confidentiality, different concepts of job roles and responsibilities. [An] example being the named person and role of health visitor and how they are struggling with the role and with children who require support and protection." (Social worker)

"Given the nature of different cultures that are in place even with the establishment of HSCPs this has not led to obvious benefits for care groups.. Often when there is good practice it is informed by individuals and not structures." (A friend of family member of mine receives, or has received care)

Some respondents also thought that there was already good alignment at the local level in some areas.

Q26 Do you think there are any risks in including children's services in the National Care Service?

A substantial proportion suggested that there would, however, be risks of including children's services in the NCS (Q26a): 205 out of the 336 (61%) individuals and 114 out of the 142 (80%) organisations that responded to this question stated "yes". There were 361 respondents who gave a reason for their response to this question. Common risks cited included:

• The potential loss of a local dimension to needs
• The level of funding that will be required and the budget that is likely to be available
• The scope of the proposals being too broad
• The dilution of multi-agency responsibility
• Inappropriate data sharing
• The potential compromise of the role of education
• The need to reflect geographic difference ie. the different needs of urban and rural locations and the Islands

Some stakeholders referred to the need for more detail on the proposals and alignment with other services as well in relation to this question.

"Shared governance and accountability arrangements that facilitate whole system governance with embedded improvement, and system and service redesign models, could be an advantage of incorporating children's services into a National Care Service, and provide an improved alternative to the status quo, with all its complexity highlighted by the Independent Care Review. Further improvement would be achieved if integrated planning and funding streams were included… The Promise Scotland welcomes the ambition expressed in the consultation, of achieving consistency in outcomes reporting, but more detailed proposals are required to give confidence in how outcomes will be consistently achieved, captured, reported and analysed." (The Promise)

"While better joint working between children's health and children's social work services is essential to achieving better outcomes for children and families, so is better joint working with education, early learning and childcare, third sector and a range of adult services. Structural change will not necessarily resolve this issue on its own." (Care Inspectorate)

Healthcare

Q27 Do you agree that the National Care Service and at a local level, Community Health and Social Care Boards should commission, procure and manage community health care services which are currently delegated to Integration Joint Boards and provided through Health Boards?

When asked whether the NCS and Community Health and Social Care Boards (CHSCBs) should commission, procure and manage community health care services (currently delegated to Integration Joint Boards and provided through Health Boards), the majority of participants agreed. This corresponds to the 279 out of 392 (71%) individuals and 101 out of 151 (67%) organisations that responded to this question.

Organisations providing care or support services, both in the private and third sectors, were more likely to agree, while two thirds of the 13 respondents that characterised their organisation as a health board, disagreed with the proposal.^[3] There were 379 respondents who gave a reason for their response. Common reasons given in support of the proposals included:

• A more streamlined and consistent service
• Greater accessibility for people accessing care and support
• A fairer system
• More collaborative and joined up working
• Better accountability

"Services should be more universal, more easily reached to those referring to them and to those who need access to them." (A friend or family member of mine receives, or has received, social care or support)

Organisations such as Social Work Scotland and the General Medical Council emphasised the importance of greater multidisciplinary working, with the latter highlighting the importance of a good organisational culture.

"Social Work Scotland supports the move of community health care services into CHSCBs. This would support the NCS aim of person centred and holistic care provision across the health and social care landscape. We also agree that, as the first point of contact for access to health services, GPs play a key role in the gatekeeping and oversight function for wider NHS access. We would recognise this as a similar role played by social workers with regard to accessing care and support through local authorities. We would recommend that both social workers and GPs retain their role of oversight and support for health and social care services within the NCS structure through CHSCBs."

"Our experience of IJBs has been that it is the culture in the respective organisations that causes the problems and gets in the way of making the arrangements work, i.e. professional rivalries, protectionism, poor multi-disciplinary working etc. It will be vital that a centrally led and controlled national care service is able to address these issues more effectively than in the past, through stronger governance and increased accountability." (General Medical Council)

"Joint commissioning, procurement and management are likely to deliver synergistic and complementary effects, ensuring a holistic approach and provision for a community's health and social care needs." (Scottish Veterans Residences)

The Allied Health Professions Federation Scotland (AHPFS) also expressed a concern that there was little reference to the role and contribution of their membership in the proposals. The need to include the views of people accessing care and support was also raised.

For those that disagreed, the main reasons were: funding availability; the relationship between health and social care; the perceived bureaucracy associated with the IJBs; and the role of local authorities.

"It would give the NHS even more dominance than is currently the case, when the problem is insufficient resources for both sectors." (A friend or family member of mine receives, or has received, social care or support, frontline care worker and social worker)

"The difficulty lies not so much in the concept but in the lack of concrete operational proposals. IJBs have often been an arena in which the NHS and local authorities have competed for limited resources. They have not shown a convincing capacity or competence to commission services. To give them (or a CHSCB) more powers without changing the culture is unlikely to work. Better to work to strengthen commissioning, procurement and management skills and competence within the NHS and local authorities before trying for further structural changes." (Individual respondent)

Q28 If the National Care Service and Community Health and Social Care Boards take responsibility for planning, commissioning and procurement of community health services, how could they support better integration with hospital-based care services?

There were 398 comments on ways in which the NCS and CHSCBs could support better integration with hospital-based care services if they take responsibility for planning, commissioning and procurement of community health services (Q28). Frequently cited reasons included:

• There was some scepticism around whether more integration is possible and the need for more detail on the proposals
• The risk of creating more bureaucracy
• Divisions relating to perceived differences in status between the NHS and care
• Conflicting targets and objectives between the two services and the need to take a person-based approach
• The need for better communication and coordination on the ground, whether by having integrated meetings or an electronic patient record

In their written submissions, the Scottish Directors of Public Health and the Royal College of Nursing, in particular, expressed concerns about the interface between primary and secondary care under the proposals and the appropriate governance arrangements.

"RCN members working in all fields… have expressed their concern that the creation of a National Care Service with the proposed responsibilities for community health and social care services will exacerbate issues which already exist at the interface of primary and secondary health care, and community based and hospital-based services. Our members are concerned that this consultation is presented without detailed consideration and proposals about how these interface problems can be avoided or how it can be improved. More broadly, the consultation document does not describe a proposal for how a National Care Service would work with the NHS, beyond the commissioning of community health care services and the proposals and questions about the role of the Health Boards' Executive Nurse Directors. People using services and the staff delivering them will encounter barriers and disjointedness appearing despite the best intentions of all involved, if there is no clarity and duty for the National Care Service and the NHS to work together to develop strategy, commissioning plans, workforce plans and service pathways on a practical and strategic level, and locally and nationally." (Royal College of Nursing)

Q29. What would be the benefits of Community Health and Social Care Boards managing GPs' contractual arrangements? (Please tick all that apply)

	Individuals	Organisations
Better integration of health and social care	247 (74%)	71 (61%)
Better outcomes for people using health and care services	231 (69%)	63 (54%)
Clearer leadership and accountability arrangements	200 (60%)	63 (54%)
Improved multidisciplinary team working	233 (69%)	65 (56%)
Improved professional and clinical care governance arrangements	199 (59%)	49 (42%)
Other	67 (20%)	46 (40%)
Total	336 (100%)	116 (100%)

When asked about the benefits of CHSCBs managing GPs' contractual arrangements (Q29), the 452 respondents to this question selected "Better integration of health and social care" most frequently (247 out of the 336 (74%) of individuals and 71 out of the 116 (61%) organisations that responded to this question). The second most frequently cited benefit was "Improved multidisciplinary team working" (233 out of the 336 (69%) individuals and 65 out of the 116 (56%) organisations that responded to this question).

Other comments (provided by 248 respondents) tended to relate to: whether GPs' contracts should be managed at a national level; the potential impact on GP recruitment and retention; the need for more detail on the proposals; and whether there were actually perceived benefits to this change. Some individuals also shared their view that GPs should not be self-employed but employed directly by the NHS.

"Where GPs are directly employed by the Health Board, the standard of motivation and enthusiasm is much less. GPs are not in control of recruitment of staff and there is no enthusiasm for improvement as it is not their own practice. Therefore the Group is not in favour of bringing GP services within the National Care Service." (Harris Locality Planning Group)

"There are benefits to be gained from closer integration with community health and GP services… The IJB reform needed to enhance these service improvements need not be radical… The vision of IRASC offers the hope that the newly empowered voice of people accessing care and support, carers, families, and community health staff will enable innovative conversations about the design and delivery of community health and GP services in future." (UNISON Scotland)

A question was also asked around the implications for other contracted services in the community by several respondents to the consultation:

"[I] would like clarity over the impact on GP contract relationships in Scotland? The same clarity is required across contracted services for Dental, Pharmacy and other contracted services in the community." (NHS Dumfries and Galloway)

Conversely, the main risk with Community Health and Social Care Boards managing GPs' contractual arrangements (Q30) identified was "Unclear leadership and accountability requirements" (222 out of the 370 (60%) who responded to this question) followed by "Fragmentation of health services (184 out of 370 respondents (50%)).

Q30. What would be the risks of Community Health and Social Care Boards managing GPs' contractual arrangements? (Please tick all that apply)

	Individuals	Organisations
Fragmentation of health services	120 (47%)	63 (56%)
Poorer outcomes for people using health and care services	99 (39%)	50 (45%)
Unclear leadership and accountability arrangements	150 (58%)	71 (63%)
Poorer professional and clinical care governance arrangements	116 (45%)	55 (49%)
Other	72 (28%)	52 (46%)
Total	257 (100%)	112 (100%)

"Other" responses (provided by 239 respondents) included the potential impact on existing GP shortages; the risk of more bureaucracy; and the potential negative impact on local services and accountability.

The General Medical Council noted that if Community Health and Social Care Boards were to take over the management of GPs' contractual arrangements, consideration will need to be given to ensuring that each Board has effective clinical governance measures in place, particularly the responsibilities outlined in the Medical Profession (Responsible Officers) Regulations 2010.

Q31 Are there any other ways of managing community health services that would provide better integration with social care?

There were 295 responses to Q31. Other suggestions of ways of managing community health care services that would provide better integration with social care commonly included:

• Increasing the use of multidisciplinary teams
• Having a single point of access
• Having locally based, integrated and co-located teams
• Having a single IT system with a digital records system
• Shared standards and objectives
• More funding for both health and social care

Social work and social care

Q32. What do you see as the main benefits in having social work planning, assessment, commissioning and accountability located within the National Care Service? (Please tick all that apply)

	Individuals	Organisations
Better outcomes for service users and their families	272 (71%)	110 (70%)
More consistent delivery of services	322 (84%)	125 (80%)
Stronger leadership	153 (40%)	74 (47%)
More effective use of resources to carry out statutory duties	244 (63%)	99 (63%)
More effective use of resources to carry out therapeutic interventions and preventative services	235 (61%)	84 (54%)
Access to learning and development and career progression	208 (54%)	85 (54%)
Other benefits or opportunities	57 (15%)	56 (36%)
Total	385 (100%)	157 (100%)

When asked about the benefits of including social work planning, assessment, commissioning and accountability within the NCS (Q32), the most frequently selected benefits were "More consistent delivery of services" (448 out of the 543 (83%) who responded to this question overall, 322 out of the 385 (84%) individuals and 125 out of the 157 (80%) organisations) and "Better outcomes for service users and their families" (383 out of the 543 (71%) overall, 272 out of the 385 (71%) individuals and 110 out of the 157 (70%) organisations).

There were 278 respondents who suggested other benefits or opportunities or who made other comments here. These responses included themes such as: more joined up working; more resources; consistency in practice across Scotland; better leadership; and raising the profile of social work in general.

"In my opinion local authorities are sadly failing in their duty currently. They are unable to meet the needs of the vulnerable and there are far too many managers. The service needs to be revamped completely and perhaps an NCS where there is improved communication and more sharing of responsibility health and social care wise." (Social worker)

"Social workers are spread thinly. We need specialised social workers identified to support the complexities involved in supporting people with profound and multiple learning disabilities (PMLD)." (PAMIS (Promoting a More Inclusive Society))

Several comments related to the need for more resourcing and funding to achieve these benefits. Several suggested that no benefits are likely to accrue unless funding and resourcing are addressed. Some respondents also highlighted a perceived lack of parity between the social work and health sectors.

"Social work as a profession has been sidelined throughout integration by health services. Integration has been largely driven by health and social work does not have the respect it deserves as a profession with health staff generally treating social workers as there to do their bidding in terms of service commissioning and provision." (Social worker)

Social Work Scotland highlighted the need to avoid creating more silos under the reforms:

"This section of the consultation… provides a fair, if very brief and partial, description of challenges faced by the profession in the current system, and our concerns about reform creating even harder edges between the siloed components of our care and health systems. Hard edges which ignore the interdependent lived reality of people's lives, and which impede the provision of holistic, empowering support and advocacy for individuals, families and communities." (Social Work Scotland)

Comments also related to, as throughout the consultation, the need for consistency and standardisation on the one hand, and responsiveness to local needs on the other. It was also highlighted in this section, again as elsewhere in the responses to the consultation, that greater clarity is required in relation to the role of Chief Social Work Officer and leadership in social work in general. There was a view that there is a risk that the role of the Chief Social Work Officer would be undermined and that it should be strengthened locally and nationally.

"The current functions of Chief Social Work Officers include professional quality assurance, governance, operational management within which social workers deliver local authority responsibilities. This role cannot be diminished in a National Care Service but must be strengthened at national and local level." (Scottish Association of Social Work)

"There is general agreement that all adult social work and social care should be included within the scope of the NCS. Again there was a desire to understand in more detail what implications there are for the role of the CSWO and a general call for more detail in relation to what is proposed." (Moray Council)

Q33 Do you see any risks in having social work planning, assessment, commissioning and accountability located within the National Care Service?

There were 443 responses to Q33 on the potential risks of having social work planning, assessment, commissioning and accountability located within the National Care Service were (Q33). Commonly cited risks included:

• The potential loss of local understanding
• The potential loss of accountability
• A potential lack of understanding of social work and a risk of it being overshadowed by other services

Some respondents highlighted the risks that the likely disruption will pose to services and costs.

"None of the above benefits have been demonstrated to be better under proposed arrangements compared to risks involved of dislocation of services and increased overheads. Also loss of local accountability through local democracy." (Representing or supporting carers and people who access care and support and their families)

"Risks include the separation from wider community planning and delivery infrastructures on which individuals and families equally rely and a disconnect from local scrutiny and accountability." (Angus Council)

"Funding and resourcing, if not properly funded and resourced, could significantly damage services and negatively impact people who require support. Having social work planning, assessment, commissioning and accountability located within the NCS adds significant responsibility which might dilute the ability to deliver on promises." (Epilepsy Scotland)

"Loss of local accountability, and recognition of services and practitioners; risk of implementing large scale solutions in small scale systems which creates unnecessary bureaucracy that diverts resources from front line care; the length of time to implement these changes risks slowing down positive changes that are already underway." (NHS Orkney)

A number of respondents also suggested there were no risks associated with the proposals in their view.

Nursing

Q34a. Should Executive Directors of Nursing have a leadership role for assuring that the safety and quality of care provided in social care is consistent and to the appropriate standard? Please select one

	Individuals	Organisations
Yes	173 (55%)	60 (50%)
Yes, but only in care homes	25 (8%)	9 (7%)
Yes, in adult care homes and care at home	51 (16%)	12 (10%)
No	65 (21%)	40 (33%)
Total	314 (100%)	121 (100%)

There was support for the leadership role of Executive Directors in assuring that the safety and quality of care provided in social care is consistent and to the appropriate standard (Q34a) with only one in four disagreeing. Over half (234 out of 436 respondents (54%)) stated "yes", nearly one in 10 (34 out of 436 respondents (8%)) said only in care homes and 14% (63 out of 436 respondents) said "Yes in adult care homes and care at home". A quarter disagreed (105 out of 436 respondents).

Organisations rather than individuals were more likely to say "no". For individuals, social workers were less convinced that the 'Executive Directors of Nursing should have a leadership role' initiative with just under a quarter (14 out of 59 respondents (24%)) of them agreeing with this statement unequivocally.

Just over half of the 60 social workers who responded to this question said "yes" compared to three quarters of respondents overall. There was also a difference in opinion between the 12 local authorities and the 16 health board representatives that responded to this question. Of the 12 local authority respondents, 6 (50%) said no, whereas of the 16 health board responses, 12 (75%) said yes.

There were 286 respondents who gave a reason for their answer to this question. These comments suggest that views are mixed: some welcomed the consistency of care this would bring, some others thought that social care would be overshadowed by nursing.

Q35 Should the National Care Service be responsible for overseeing and ensuring consistency of access to education and professional development of social care nursing staff, standards of care and governance of nursing?

A majority also supported the NCS being given responsibility for overseeing and ensuring consistency of access to education and professional development of social care nursing staff, standards of care and governance of nursing (Q35a) with two thirds of the respondents agreeing (267 out of the 418 (64%)) that responded to this question).

Just over a quarter thought it should be the responsibility of the NHS (108 out of 418 respondents (26%)). Individuals tended to be more likely to say it should be the responsibility of the NHS (84 of 308 (27%) compared to 24 of 109 organisations (22%).Those that agreed that it should sit in the NCS tended to suggest that this was to:

• Break down any stigma around care
• Provide fair access to training
• Create consistency in standards
• Promote equity across all services

Comments in relation to this issue included:

"Yes. If the National Care Service is responsible for these areas of practice, and this workforce, then it should also have responsibility for overseeing and ensuring consistency of access to education and professional development. Social workers employed within these services should continue to be aligned to the SSSC, with the constructive additionally of the National Social Work Agency to support wider workforce planning and development." (Social Work Scotland)

Those that stated it should be the responsibility of the NHS suggested a range of reasons why, including the existing expertise and structures in the NHS and the need for education and professional development to stay within the relevant professional bodies.

"[A] dilution of skilled leadership across many different bodies would lead to potential inconsistencies and delivery. Nursing is largely situated within the NHS and it would be good to see the governance of all nursing sitting in single structures. This I would foresee extending to specific training opportunities for care at home staff also allowing a better service user experience." (Ayrshire and Arran Local Medical Committee Limited)

"There should be one standard for nurses overseen by the NHS and the NMC. Creating a two tier system will give the impression of nursing with the social care field as being secondary to NHS nursing and reduce the number of nurses willing to work within the social care sector." (Person accessing care and support and social worker)

"As is proposed above, professional leadership will be undertaken by the Executive Director of Nursing in the Health Board to then give responsibility of overseeing professional development etc. to the National Care Service appears to further confuse the issue. The approach which makes most sense would be to align the professional leadership with the governance responsibility and have this as part of the role of the Executive Director of Nursing. This would offer nurses working in the social care field the same opportunities as those working within the NHS." (MS Society Scotland)

"[The] technical competence of Nursing must remain with the NHS otherwise nursing skills will be insufficient." (Carer and Person accessing care and support)

"I'd like to see it sit within the remit of the Chief Nursing Officer for Scotland and the highly effective national nursing governance framework that exists. This should apply across nursing no matter where it is delivered." (Individual who works or has worked in the management of care services)

Q36 If Community Health and Social Care Boards are created to include community health care, should Executive Nurse Directors have a role within the Community Health and Social Care Boards with accountability to the National Care Service for health and social care nursing?

There was strong agreement when the consultation asked whether, if CHSCBs are created, Executive Nurse Directors should have a role within the Boards which has accountability to the NCS for health and social care nursing with 312 of the 397 (79%) respondents to Q36a stating "yes". Individuals tended to be more positive than organisations about this proposal ((233 out of 291 respondents (80%)) of individuals versus (78 out of 105 respondents (74%)) of organisations), however a lower proportion of individual social workers agreed (35 out of 53 respondents (66%)).

There were 163 responses to the free text element of this question. Alternatives suggested included the NHS and the need to include other relevant professionals. The Royal College of Nursing in Scotland emphasised that the role of the Executive Nurse Directors should be clearly defined and that accountability should be at the corporate rather than the individual level. The Executive Nurse Directors Group also called for greater clarity around accountability.

"The scope of the role of Executive Nurse Directors, or their Community Health and Social Care Board equivalents should be clearly defined. The distinction between the areas for which they will be responsible and accountable and those of other roles with statutory functions - for example, the Director of Public Health or the current Chief Social Work Officer - should be unambiguous and transparent. It is important that the ultimate responsibility and accountability for nursing staffing, standards and governance is corporate - it is the Board, whether the NHS Board or the Community Health and Social Care Board, that must be accountable, rather than an Executive Nurse Director or any other individual Board or staff member." (Royal College of Nursing)

"Our preference would be for nurse directors to have oversight across the NHS and CHSC boards with the ability to delegate to a nurse on the CHSC board. This would allow the Nurse Director to exert the influence and leadership necessary at regional and local levels to continuously improve peoples' quality of care. However greater clarity is needed on lines of accountability to the NHS and NCS, the role of the CNO and the roles of supporting national organisations." (Scotland's Executive Nurse Directors Group)

Justice social work

Q37 Do you think justice social work services should become part of the National Care Service (along with social work more broadly)?

A majority who responded to Q37a (241 out of 388 respondents (62%)) agreed that justice social work should be included in the remit of the NCS. There was no real difference between individuals (176 out of 287 respondents (61%)) and organisations (64 out of 100 respondents (64%)) in agreement with this statement.

There were, however, some differences by groups: frontline care workers (62 out of 86 respondents (72%)); care providers and support organisations, private sector (4 out of 6 respondents (67%)) were more positive about the proposals and social workers (45 out of 85 respondents (53%)) and respondents who stated that they worked in local authorities (3 out of 14 respondents (21%)) less so. Please note that the number of respondents in some of these groups is relatively low so caution should be taken in considering or interpreting any potential differences by subgroup.

There were 278 respondents who gave a reason for their response. Reasons given by those who agreed included:

• The need to keep all forms of social work together so that justice social work staff and people accessing care and supports are not isolated
• Keeping standards consistent
• Offending behaviour is often linked to other care needs
• Integrated services are more likely to be effective
• Equitable access across Scotland

Other comments relating to justice social work emphasised the need for joined-up working:

"If the purpose of NCS is joined-up working that improves the care of people needing care then justice work must be part of this. People are 'whole people' and to separate justice would be seeing people in the justice system as 'defined' by that part of themselves. And people move in and out of the justice system so a joined up way is important." (Person accessing care and support and someone who is or has been a frontline care worker)

Several respondents again highlighted the need for more detail on the proposals, with the Criminal Justice Voluntary Sector Forum (CJVSF) highlighting, for example, that the changes in the Community Justice (Scotland) Act 2016 were introduced following a long consultation and development process and evidence is only now beginning to emerge and to be analysed as to the impact of the changes. CJVSF called for more analysis to be undertaken of the advantages and disadvantages of Justice Social Work being incorporated into the proposed NCS. This was echoed by the Glasgow City Health and Social Care Partnership:

"Services such as justice social work services are most effective when located within the localities in which such services are provided. [We] have indicated in the negative for this question. However if proposals for the NCS go ahead and the issue of scope is within that context [we] think Justice Social Work should be included. However there remains a level of concern regarding the lack of detail of what this will mean for Justice Social Work within the consultation document and potential substantive consequences of a National Care Service for Justice Social Work. We also note the lack of consultation and independent review of Justice Social Work ahead of the publication of the consultation paper. [We] however see the benefit of moving with our social work profession to a NCS… and would have concerns if Justice Social Work was to sit separately to this arrangement." (Glasgow City Health and Social Care Partnership)

The third of respondents who disagreed, gave reasons such as:

• The proposed NCS is too large and centralised
• There is a need to reflect local requirements
• Justice social work should remain with local authorities
• Justice social work is a specialism

Social Work Scotland stated that this question was difficult to answer in a binary format:

"As with previous and subsequent questions in this 'scope' section, the issues at play are too complicated, and the detail provided on the NCS structure too limited, to answer 'yes' or 'no'... [A]fter much debate, we have concluded that a commitment to maintaining a united profession is not sufficient grounds to support all social work services moving into the NCS. Each discipline within social work operates in unique contexts, and the relative merits of inclusion in the NCS need to be assessed thoroughly for each, alongside alternative reforms. We do not deny or reject that the changes proposed in the consultation might represent improvement, but more work is needed to ensure that they represent the best possible next step in the reform of critical public services." (Social Work Scotland)

The Promise highlighted the Independent Care Review finding that a criminal justice response was often inappropriate for children and young people who have experience of Scotland's 'care system':

"Support needs to be put in place at the earliest opportunity, and prior to escalation into offending… There is opportunity within a National Care Service to ensure that a more holistic and trauma informed approach is taken with children and young people caught up in the care and justice 'systems'... If this proposal is adopted, there must be sufficient community-based alternatives provided when offending does take place." (The Promise).

"Community Justice is a broad agenda. There are concerns about the uncertainty caused by the consultation proposals concerning both The Promise and the likely Children's Social Work shift to a position outside Local Authorities. Both the Promise and Children's Social Work are important parts of early intervention work. Presently, there is a great deal of policy work ongoing and it is not clear how this will join up. There are also a range of strategies that should be aligning. As a result, the implications of the consultation could make this a very complex landscape." (COSLA)

Q38 If yes, should this happen at the same time as all other social work services or should justice social work be incorporated into the National Care Service at a later stage?

Almost a third of respondents to the section on the possible inclusion of Justice Social Work in the NCS, did not answer the question on the timing of such a move (Q38a). Of those who did answer, 166 out of 268 respondents (62%) thought that it should happen at the same time as other social work services. There were 197 respondents who gave a reason for their response. Reasons given included, amongst others:

• The need for consistency with other services
• The sense that if reform was done in a piecemeal form, it may not happen at all
• The need to maintain parity with other branches of social work

NHS National Services Scotland, for example, highlighted the need for a whole system approach in relation to social work and justice social work.

"Again this supports the whole system approach around social work and justice social work systems, data and service planning, to deliver effective prevention and intervention attributes. This can support improved outcomes, integrated financial planning and resource allocation on a case by case basis." (NHS National Services Scotland)

Those who thought it should move at a later stage suggested:

• The complexity of the changes to be made
• The size of the proposed new organisation
• The length of time it will take to incorporate the other services

"To change everything immediately could pose huge risk, perhaps a phased approach including incorporating lessons learned from other areas or similar work would enable a more sustainable way forward. Engaging with local people, their families, Carers and communities would be essential to the whole process." (Person accessing care and support)

Q39. What opportunities and benefits do you think could come from justice social work being part of the National Care Service? (Tick all that apply)

	Individuals	Organisations
More consistent delivery of justice social work services	142 (73%)	52 (68%)
Stronger leadership of justice social work	77 (40%)	37 (49%)
Better outcomes for service users	143 (74%)	55 (72%)
More efficient use of resources	130 (67%)	48 (63%)
Other opportunities or benefits	47 (24%)	31 (41%)
Total	194 (100%)	76 (100%)

Nearly three quarters of respondents to Q39 agreed that the main potential benefits of justice social work being included in the NCS might be "More consistent delivery of justice social work services" (195 out of 271 respondents (72%)) and "Better outcomes for service users" (199 out of 271 respondents (73%)) with nearly three quarters of respondents to this question citing both. Out of the 271 responses to this question, 194 respondents classified themselves as individuals and 76 as organisations.

There was no real difference at the overall level between individual and organisations at Q39, although organisations did tend to identify "Stronger leadership of justice social work" as a benefit compared to individuals (36 out of 76 (47%) of organisations which responded to this question compared to 77 of the 197 individuals (40%) who responded to this question). There was no real difference across the subgroups, with the exception of people accessing care and support and unpaid carers who were more likely to select "More consistency of services" (22 out of 26 (85%) people accessing care and support and 70 out of 88 (80%) of unpaid carers). Please note however that the number of people accessing care and support responding to this question is relatively low so caution should be taken in interpreting this figure.

When asked to suggest other opportunities or benefits, respondents (182) gave a range of responses, including:

• Greater consistency across different services
• A more multi-service approach to issues and greater collaboration
• Better outcomes for individuals who have committed offences
• It enables a holistic approach to the people accessing care and support' wider family
• Potentially less stigma for the person accessing care and support

Several respondents said there would be no benefits and a few said there would need to be more detail and more consultation before they could comment.

There was little difference in respondents' level of agreement with each of the potential risks and challenges, as listed in the question (Q40):

• Less efficient use of resources (123 out of 239 respondents (52%))
• Worse outcomes for people accessing care and support (120 out of 239 respondents (50%))
• Poorer delivery of justice social work services (116 out of 239 respondents (49%))
• Weaker leadership of justice social work (115 out of 239 respondents (48%))

There were 194 respondents who provided a free text comment at Q40. Other risks that were identified here included:

• A loss of focus for justice social work
• A loss of "voice" for justice social work given its relatively small size in relation to the other services
• A loss of specialist knowledge - there was also a view that leadership and management should have a professional justice background
• A dilution of services due to competing demands and the potential risk to the ring-fenced justice social work budget
• The need to balance consistency with meeting local needs, especially in rural and remote areas
• Cultural differences between the agencies

Again, as previously in this section, some respondents highlighted the need for greater detail on the proposals before they could comment in more depth.

"The partnership views the consideration given to Children and Families and Justice Social Work (JSW) within the document as insufficient to appropriately reflect and consult upon the complexity of service planning and delivery, including partnership working required to meet the needs of people within these areas of social work." (North Lanarkshire Community Justice Partnership)

Q41. Do you think any of the following alternative reforms should be explored to improve the delivery of community justice services in Scotland?

Respondents were asked whether any alternative reforms, from a list of options, should be explored, with the aim of improving the delivery of community justice services in Scotland at Q41.

For individuals, half selected "Establishing a national body that focuses on prevention of offending" (113 out of 226 respondents (50%)), followed by 30% who said "Establishing a national justice social work service/agency with responsibility for delivery of community justice services" (68 out of 226 respondents (30%)).

For organisations, "Establishing a national body that focuses on prevention of offending" was also selected most frequently (24 out of 76 respondents (32%)), followed by "Retaining local authority responsibility for the delivery of community justice services, but establishing a body under local authority control to ensure consistency of approach and availability across Scotland" (21 out of 76 respondents (28%)).

Only ten respondents in total (10 out of 303 respondents (3%)) stated that there should be no reforms at all. There were 138 free text responses to this question. In general, respondents did not tend to suggest alternative reforms at Q41. Instead, comments were provided around:

• Hybrid models balancing national and regional control
• The need for more resourcing and funding for Community Justice Services
• The need for a focus on prevention and rehabilitation

Again, there was some feedback that there was insufficient detail in the consultation document to comment. Several respondents stated that there should be a review of the current system of community justice services in Scotland before any reforms are undertaken.

Q42 Should community justice partnerships be aligned under Community Health and Social Care Boards (as reformed by the National Care Service) on a consistent basis?

When asked whether community justice partnerships be aligned under the proposed "Community Health and Social Care Boards" on a consistent basis, nearly two thirds of the respondents to Q42a agreed (201 out of 323 respondents (62%)).

There were 323 responses to this question, of which 242 were from individuals and 80 from organisations. There was no real quantitative difference between individual and organisation responses to Q42. There were 171 respondents who gave a reason for their response to this question. Reasons given by respondents who agreed to this question included:

• Streamlined delivery and reduced duplication of work
• Consistency
• The benefits of aligned boundaries between different statutory organisations
• A desire for national standards and local delivery

One respondent also highlighted the needs of "fragile" island communities in this regard.

For those that disagreed (121 out of 322 respondents to this question), 63 respondents provided a reason for their disagreement. These included: the need for an alignment with the justice system rather than social work; the impact on existing arrangements including Community Justice Partnerships; and the risk that justice social work would become marginalised in a broader organisation.

Prisons

Q43 Do you think that giving the National Care Service responsibility for social care services in prisons would improve outcomes for people in custody and those being released?

A majority of respondents (233 out of the 324 (72%) who responded to this question) agreed that giving the responsibility for social care services in prisons to a National Care Service would improve outcomes for people in custody and those being released.

There was no real difference in response between individuals and organisations who responded to this question. However, amongst those respondents that receive, or have received, social care or support tended to demonstrate lower levels of agreement with the proposal to give the National Care Service responsibility for social care services in prisons (22 out 37 respondents (60%)).

Overall, there were 217 free text comments on this question. Reasons given by those who agreed with the proposal included:

• Increased support for prisoners with mental health problems or learning disabilities
• Smoother transitions at the point of release
• Higher standards of service and potentially reduced offending
• The need for the human rights of prisoners to be respected
• The ageing prisoner population and the subsequent need for greater support for this group

There was a view in some quarters that this would lead to a much more joined-up approach.

"The current system operates very much in isolation, linking more closely and affiliating with the national service will encourage greater alignment to local assets within the control of the NCS." (NHS Borders)

Of those that disagreed with giving the responsibility for social care services in prisons to the NCS, 49 of the Citizen Space respondents gave a reason for their responses. Common themes included:

• The need for a local approach and for strong links between prisons and community-based services, especially at the time of release
• The complexity of social care in prisons and the risk that this complexity might delay the introduction of the NCS
• The need for increased budgets and more staff
• The lack of evidence to support the change given that prison social care was not included in the IRASC

"The difficulty with social care in prison is the relationship between guards who quite rightly have to ensure safety in prisons and maintain rules and social care workers who work with acceptable risk and who will challenge rules that unnecessarily discriminate against those who require social care. If a National Care Service can give social care workers the gravitas that they deserve in prisons so that they are seen as equal professionals that would have a significant impact. In terms of those being released, linking in with the local services would result in a better outcome rather than a national service." (Individual respondent)

"Our members provide care to those with severe mental illness in a prison setting, who have specific support needs from both clinical and social care. We would be concerned that rolling these services into a National Care Service body would significantly dilute the specialism and the expertise that is already in place to meet their needs. We are also unsure whether the case is made here for the benefits of transferring responsibility. Those who are moving out of forensic settings, though, often fall between gaps in care delivery between forensic settings and whole-population services. Including this population of 'leavers' within the wider system, if possible, could potentially address these barriers. Further detail on how this would be achieved is needed." (RCPsych in Scotland).

Some of those that disagreed with the proposals stated that the proposals required further consideration and also more investment.

"It is not clear what additionality would be gained by having prison social care fall under a NCS." (Midlothian Council)

"There is no need for a National Care Service but there is a requirement to ensure consistency of social care both within and outwith prison." (Person accessing care and support and social worker)

Q44 Do you think that access to care and support in prisons should focus on an outcomes-based model as we propose for people in the community, while taking account of the complexities of providing support in prison?

A large majority (311 out of the 341 (91%)) of those that answered Q44 thought that access to care and support in prisons should focus on an outcomes-based model. Organisations were slightly more likely to say "yes" than individuals. In line with responses seen at Q43a for individuals, a lower proportion of respondents that receive, or have received, social care or support the idea of an outcomes-based model approach for prisons (27 out of the 36 (75%) respondents to this question).

Of the 341 respondents that said yes, 151 gave a reason for their response. Some of the themes emerging from the comments provided included:

• The need for high standards of care regardless of setting
• The need to take a human rights-based approach
• The need for personalised care plans

Specific comments provided in this context included:

"Yes, each prisoner should have an outcomes focused care plan in place supported by a holistic assessment. This should consider what services are required during [the] sentence which flows seamlessly into the community. This would ensure that prisoners get access to the right support and treatment in prison and a rehabilitation plan in place for release." (Aberdeen City Council)

"The views and wishes of individuals are central to a human rights-based approach, and in delivering person-centred outcomes. They should therefore be promoted at every stage during a person's imprisonment and to ensure a successful, seamless reintegration to the community upon release." (The Care Inspectorate)

"This "outcomes based model" is just jargon. But the criminal justice system requires partnership working. For decent housing links to local authorities will be crucial. The proposed attack on local authorities and their workforce that the proposed removal of all their responsibilities represents would appear to be a superb way of reducing the effectiveness of through care and aftercare, whilst hiding behind the jargon enshrined in the focus on "outcomes"." (Carer and social worker)

Alcohol and drug services

Q45 What are the benefits of planning services through Alcohol and Drug Partnerships?

The main benefits of planning services through Alcohol and Drugs Partnerships (Q45) were: "Better coordination of Alcohol and Drug Services" (267 out of the 328 (81%) who responded to this question) and "Better outcomes for service users" (246 out of the 328 respondents (75%)). Organisations were more likely to say "Stronger leadership of Alcohol and Drug services" than individuals (59% and 47% respectively).

Other benefits cited included:

• Multidisciplinary approaches and partnership working
• A senior focus on issues that were perhaps on the periphery of care in the past
• Local knowledge and insight into current challenges
• Support for children in families who may be at risk of substance abuse

Some of the comments provided in relation to this question referenced the importance of tailored solutions and the need for collaboration between services.

"Tailored solutions in response to local need and reflecting local resources." (Orkney Integration Joint Board)

"Alcohol and Drug Partnerships have an important role to play in bringing together a range of organisations who work with people living with harmful substance misuse. The collaborative approach has the potential to facilitate the development of important and shared understanding across services, with better knowledge about the impact of parental drugs and alcohol misuse on children." (NSPCC Scotland)

Q46 What are the drawbacks of Alcohol and Drug Partnerships?

The main drawback of Alcohol and Drug Partnerships (ADPs) was thought to be "Confused leadership and accountability" as selected by the 166 out of 241 respondents (69%) that answered this question (Q46). This was more so the case for individuals (116 out of 159 respondents (73%)) than organisations (48 out of 80 respondents (60%)). There were 171 respondents who provided a free text comment here. Other drawbacks suggested by this group included:

• A perceived lack of clear leadership in some areas
• A perceived lack of accountability in partnership working
• The need to include the views of those with lived experience
• The need to account for local variations
• Support is provided on a Monday to Friday basis rather than around the clock

"Ensuring that there are effective links between ADPs and local governance will be critical. However, much greater clarity is needed to understand the relationship between the ADP as a commissioning and delivery body between the NHS Board and Local Authority and the NCS." (Scottish Directors of Public Health group)

Q47 Should the responsibilities of Alcohol and Drug Partnerships be integrated into the work of Community Health and Social Care Boards?

A large proportion (276 out of the 361 (77%) respondents to this question) agreed the responsibilities of the Partnerships should be integrated into the CHSCBs. There was no real difference between responses from individuals and organisations. Some of the reasons provided by the 131 respondents who agreed with this proposal included:

• Greater accountability
• More consistency and coordination and cross-boundary working
• A holistic approach to individual needs
• Greater integration of services
• Alcohol and drug addiction is recognised as a major factor in negative outcomes
• There is a need for a national, standardised approach
• There is a need for a focus on education and preventative measures

"There are some clear benefits, particularly when looking at this from the perspective of those with complex needs, who would most benefit from integrated services which consider the wider needs and disadvantages which would must be addressed in order for recovery to be progressed and maintained. These themselves though are not an argument for reorganisation as proposed as they are already part of IJBs and the present HSCPs." (Cyrenians)

Q48 Are there other ways that Alcohol and Drug services could be managed to provide better outcomes for people?

Respondents were asked if there were better ways of managing Alcohol and Drug services to provide better outcomes for people (Q48). There were 212 responses to this free text question. Common examples provided by respondents included:

• Better linkages with mental health services
• Better access to services outside the service users' local authority area
• More joined up working and multidisciplinary teams
• More preventative work and education
• More funding and staffing
• Involving people with lived experience in ADPs

Q49 Could residential rehabilitation services be better delivered through national commissioning?

A large majority (254 out of the 317 (80%) that responded to Q49) agreed that residential rehabilitation services could be better delivered through national commissioning. Individuals were slightly more likely to agree than organisations (82% compared to 76%).

There were 218 respondents that gave a reason for their answer. These included:

• Better access to services, including residential rehabilitation, outside the service user's local authority area, ending a perceived "postcode lottery"
• More consistency of approach across Scotland
• Economies of scale

There were several comments about the need for more residential settings in general. Those that said "No" at Q49a tended to reference the need for local solutions.

"There is a risk that if a national approach was adopted then it would be weighted towards those areas with greatest need and inhibit innovation and responsiveness at a local level." (Community Planning Aberdeen)

Q50 What other specialist alcohol and drug services should/could be delivered through national commissioning?

When asked what other specialist alcohol and drug services could or should be delivered through national commissioning (Q50), suggestions from 181 respondents to this question included:

• Detox support
• Family support
• Education and prevention services
• Specialist services

"There is a strong requirement to better support people within their local communities - this needs far greater investment into local third sector organisations - and also procurement processes that are longer term to allow sustainability of services and development of local expertise and trust." (Primary Care Leads network)

The importance of close links between alcohol and drugs services and mental health services was also highlighted:

"Mental health and substance use support needs to become further integrated. We know it can be extremely difficult for people to access support for both substance use and mental health, and understand the Scottish Government is aiming to achieve integration through a National Care Service." (Scottish Families Affected by Alcohol and Drugs (SFAD); Scottish Recovery Consortium (SRC))

Q51 Are there other ways that alcohol and drug services could be planned and delivered to ensure that the rights of people with problematic substance use (alcohol or drugs) to access treatment, care and support are effectively implemented in services?

Finally, in this section, the consultation asked whether there are other ways in which alcohol and drug services could be planned and delivered to ensure that the rights of people with problematic substance use to access treatment, care and support are effectively managed (Q51). There were 208 comments on this question. Common themes included:

• The importance of giving people with lived experience a voice in services
• Linked to this, the importance of peer-to-peer support
• Early intervention and the need to avoid lengthy referral routes
• The need for more resources
• More collaboration between the relevant services

The need for ownership of a person's care and the links between addiction and mental illness was highlighted by one person accessing care and support:

"For care to be successfully implemented it needs to be at the centre of everything. This might mean having people with lived experience working to deliver support: to care is to readdress power imbalances too. A better understanding on how drugs and alcohol affect not just the individual, or even the wider economy, would help services become more community focused and less stigmatised. Scotland is suffering an epidemic of sadness: deaths from alcohol, drugs and suicide are causing a totally different bereavement process for those these deaths leave behind. An important issue with the integration of mental health and recovery services concerns lack of ownership for a person's care. There is ample research that tells us that mental illness and addiction go hand in hand, but it's so often the case that people within the system are pushed from one service to the other." (Person accessing care and support)

Mental health services

Q52 What elements of mental health care should be delivered from within a National Care Service?

Over 400 people responded to the question on the elements of mental health care should be delivered from within an NCS (Q52). There was a consistent percentage of around three quarters that agreed that: primary mental health services; Child and Adolescent Mental Health Services: Community mental health teams; Crisis services; Mental health officers and Mental health link workers should all be delivered from within an NCS. In particular, almost nine in ten frontline care workers, within the individual grouping, suggested that community mental health teams should be delivered from within the NCS.

A wide range of "other" comments were given in relation to this question (from 252 respondents), referring to diverse issues including:

• Perceptions that current funding and resourcing levels for mental health are not sufficient to meet demand
• The need for better and more timely access to mental health services
• Recruitment and retention of mental health staff
• The need to improve the transition from CAMHS to adult mental health services

Some used this space to suggest that mental health services should remain in the NHS. There were also several comments in this section that there were not enough details in the consultation to comment on the proposals.

"Clarity is needed as there is very little detail relating to mental health services in the consultation document." (NHS Dumfries and Galloway)

"The consultation document leaves a great deal of room for interpretation and in order to understand the risks and opportunities of any proposals, a more clearly defined proposal for these services would need to be developed together." (NHS Scotland Board Chairs and Chief Executives)

Q53 How should we ensure that whatever mental health care elements are in a National Care Service link effectively to other services e.g. NHS services?

When respondents were asked how the Scottish Government should ensure that the mental health elements in the NCS link effectively to other services e.g. NHS services (Q53), 338 comments were provided. These comments tended to reference themes such as:

• The need for quicker referrals
• Increased use of multi-disciplinary teams
• Improved communication across all services, including better information sharing i.e. through single electronic records
• Closer alignment and joint working between NHS Scotland and the proposed NCS
• The importance of accountability at all levels
• The need for more funding for mental health services

Specific comments included:

"Collaboration is key, with services integrated as much as possible." (Psychological Therapies for Older People NHS Lanarkshire)

"It is generally accepted that there is a mental health crisis in Scotland with existing services unable to deal with the volume of referrals. Tackling this will require a multi-agency approach (NHS, NCS and Third Sector) with the most serious cases being treated by specialists within the NHS.. [the] third Sector and NCS working closely to deliver care. Shared information and joint working between mental health teams and caregivers is essential." (ME Action Scotland)

"We would suggest that bringing mental health under one area would improve services, but moving further away from the NHS would be a risk." (Ayrshire and Arran Local Medical Committee Limited)

"It is important to consider that humans are complex beings and that defining people with either physical or mental health problems may not fully meet population needs and individual needs may not meet with traditional service eligibility criteria. A 'No Wrong Door' policy in mental health should be the ordinary approach in both NCS and NHS services. Early intervention and prevention are key to ensuring people's needs and are met before they reach an acute level. Additionally, social care staff should be embedded directly within mental health teams and services to ensure effectiveness or vice versa." (The Royal College of Occupational Therapists)

There were some comments about the needs of specific groups of people with learning disabilities or conditions such as autism and the need for consistency and training for care workers in relation to their requirements:

"Autistic people often have experience in falling between the gaps in mental health care services. This occurs where there are local criteria for accessing specific services and no service identified for those that do not meet these criteria and yet still have mental health challenges. This can be compounded by lack of knowledge of autism within some specific teams. Therefore a more consistent approach where problems can be identified at a national level and solutions and responsibilities clarified would be welcomed." (Organisation respondent)

Overall, around two thirds (26 out of the 40 (65%)) of Easy Read respondents agreed that all the areas listed should be in the scope of an NCS (Q12). There was a strong majority agreeing that all mental health services (Q13) should be in scope: the top two responses were primary mental health services and community mental health teams (32 out of 39 respondents (82%) for both).

National Social Work Agency

Q54 What benefits do you think there would be in establishing a National Social Work Agency

There were relatively high levels of agreement with the suggested benefits of establishing a National Social Work Agency amongst the 448 people that gave a response to this question (Q54) as follows: improving training and Continuous Professional Development (385 out of 448 respondents (86%)); supporting workforce planning (346 out of 448 respondents (77%)) and raising the status of social work (345 out of 448 respondents (77%)).

There were 227 respondents that provided a comment on this question. Other benefits identified by them included:

• Greater consistency in social work standards across Scotland
• Greater empowerment of the profession
• Improving understanding and therefore the profile of social work
• Potential consistency in pay grades and scales
• Potential to deliver clear leadership for the sector

"For those working in and leading the profession, the establishment of a National Social Work Agency is a vital piece in the jigsaw of reform, providing the levers we collectively need to plan, develop and improve social work in Scotland. It will be complementary to existing bodies, assuming responsibilities that currently no one holds, and bringing greater coordination in areas where various partners have a role." Social Work Scotland

"The Health Board supports the role of a national agency to raise the status and profile of social work." (NHS Forth Valley)

"There would be greater consistency if it allows social work to speak with one voice and establish equality in practice across the many areas in which qualified workers operate- local authorities, third sector, hospitals, prisons etc. This should better prepare newly qualified social workers for their role." (Sacro)

Q55 Do you think there would be any risks in establishing a National Social Work Agency?

There were 320 responses to this free text question. Many respondents did not foresee any risks to the establishment of a National Social Work Agency. The risks that were cited tended to relate to:

• The potential for increased bureaucracy
• The loss of local knowledge and practices if there is too much centralisation
• Risks that the transition phase may result in harm to people accessing care and support

"A national approach may overlook the different requirements at a local level and or take an approach to workforce planning which doesn't recognise difference and looks to a one size fits all model." (Social Worker)

Q56 Do you think a National Social Work Agency should be part of the National Care Service?

There was also a majority of respondents in favour of the proposed agency being part of the NCS (Q56a) (280 out of the 423 (66%) that responded to this question). At the overall level, there was no real difference between the responses of individuals and organisations. However, respondents identifying as social workers are less likely to agree that a National Social Work Agency should be part of the National Care Service (49 out of 105 respondents (47%)). Reasons given by those that agreed with the proposals included:

• The need to raise the profile of social work
• The integration of social care and social work
• Easier access to a range of services
• A reduction in duplication and more streamlined services

"It is important that professional social work is not separated from social care more widely but interfaces with it." (UNITE Edinburgh & Forth Not For Profit Branch)

"It is important that professional social work is not separated from social care more widely but interfaces with it." (Scottish Hazards)

Those that disagreed tended to state that they disagreed with the concept of a National Care Service and had concerns around centralisation.

"I am opposed to centralisation unless it is restricted to certain areas of work. We need to ensure that central control does not affect the localised delivery of service that is able to adapt to the unique circumstances and needs of the different areas of Scotland." (Person accessing care and support)

Q57 Which of the following do you think that a National Social Work Agency should have a role in leading on?

In terms of where the leadership responsibilities of the proposed Agency should lie (Q57), the top three responses were: social work improvement (355 out of the 437 (81%) that responded to this question); social work education (358 or 82%); and a national framework for learning and development (356 or 82%). "Other" responses (provided by 167 respondents) included: a standardised approach to complaints and accountability; and social workers' terms and conditions. Several respondents asked how the National Social Work Agency would interact with the Scottish Social Services Council and other existing bodies.

"I think it is safe to say that if a National Social Work Agency were to be established there would need to be very careful consideration given to its relationship with a wide range of other entities currently in existence inter alia the SSSC, CoSLA, the Care Inspectorate, CELCIS, CYCJ, universities, SASW, the SWU." (Social worker)