National Care Service: island communities impact assessment

Key Findings

NCS Structures and Governance

The NCS is intended to exercise the responsibility for social care that is being transferred to the Scottish Ministers. The NCS will, in practice, comprise a part of Government to act at national level and the local care boards that will be set up to plan and deliver services locally.

At a national level, the Scottish Government intends to establish the NCS either as an Executive Agency or as a part of the core Scottish Government. In both cases, it would be staffed by civil servants and will share the legal identity of the Scottish Ministers. The local care boards will be separate public bodies of the Scottish Government and have their own legal identity. This new part of Government will provide effective leadership, oversight, and accountability for social care. It is also expected that the NCS, nationally and locally, will have a role in relation to the Scottish Ministers' existing responsibility for community health, in order to deliver effective integration at national as well as local level (the transfer of functions to the NCS is addressed separately, below).

The key change that the establishment of NCS will introduce is that Scottish Ministers will be accountable for the delivery of social care and social work in the same way as they are accountable for health care at present. Scottish Ministers will have to do this in line with the NCS Principles that are set out in the Bill. In practice, this means that the Scottish Government will set standards and frameworks at the national level, and will be responsible for ensuring these are put into practice on the ground through performance monitoring and improvement.

The Bill provides the powers necessary for the Scottish Ministers to establish and oversee local care boards, which will plan and commission services for their local area. Services will therefore continue to be designed and delivered locally. It is expected that community health services will continue to be delivered by the NHS, as commissioned by the local care boards.

Many social care services currently provided in-house by local authorities work well. For that reason social care services currently provided in-house by local authorities may continue under contractual, grant or alliance arrangements with the local care board, or the local care board may take over direct delivery, with staff transferring to the local care board. These will be decisions to be taken locally as the local care boards are established.

The details of the way the NCS will be established nationally and locally will be developed in collaboration with people with lived and living experience of the community health and social care system, partners and stakeholders to ensure that it operates in a way that supports those it is designed to help. That process will determine the most appropriate governance mechanisms to ensure that local flexibility is maintained and community engagement is integrated into service planning and delivery within a national framework that ensures consistency and drives improvement. These details will be designed within the overarching framework provided for by the Bill, including the NCS principles, and set out in the policy memorandum.

In particular, further consultation and co-design with people with lived experience, alongside key stakeholders and delivery partners will determine details relating to:

• The number of local care boards and the geographic areas they will cover
• The composition of the boards and their relationship with the national NCS structures
• The duties, functions and services they will provide, both directly and commissioned from other bodies
• Workforce, employment and contractual arrangements (including transfer of staff from local authorities as appropriate)
• The impact on other bodies, including local authorities and NHS Boards
• How to maintain and strengthen integration between NHS and NCS bodies.

The approach to the structures and governance of the NCS has been carefully designed to mitigate the concerns raised by island community stakeholders, particularly around maintaining local accountability and avoiding additional bureaucracy. The overarching framework for the NCS and its local care boards set out in the Bill is designed to ensure that local accountability is maintained while also providing for consistency and improvement to be led at the national level. This will be achieved by ensuring that local care boards have appropriate oversight and representation on their boards, including from local people with lived and living experience and by ensuring that the NCS at the national level is designed to be supportive rather than prescriptive.

One of the intentions of the NCS is to reduce bureaucracy and simplify the governance of community health and social care. Measures to improve care and ensure consistency across Scotland will inherently entail the creation of governance structures at the national level. These new structures will be focused on ensuring that all care standards and expectation are joined-up, consistent, and clear so that local care boards and social care providers are supported and have clarity on what is expected of them. By assuming responsibilities for community health and social care, the NCS can ensure that requirements in both of these areas are better aligned and that social care policies already set at the national level (including Self-directed Support and care standards) are integrated into an overarching framework for all of social care.

The new local care boards will replace existing Integrated Joint Boards (IJBs), taking over their roles in planning and commissioning community health and social care and taking on a more direct role in procuring and delivering social care services as appropriate. These new bodies will take on and benefit from the existing expertise of staff currently fulfilling these functions. The intention is therefore not to add a new layer of bureaucracy at the local level, but to replace an existing layer. Discussions with Island communities will continue throughout the design stage in acknowledgement of the specific circumstances they might face is supporting any new administrative bodies.

The key measure to ensuring that the governance of the NCS achieves its goals of maintaining local flexibility and minimising the impact of any new bureaucracy is the co-design process. The details of how the NCS will operate is being developed in conjunction with people with lived and living experience to ensure that the system is shaped by their needs, along with delivery partners and key stakeholders. As these proposals are developed, further impact assessments will be undertaken to ensure that the impacts of the new proposed structures and governance arrangements are fully accounted for.

National Social Work Agency

As part of the NCS, a National Social Work Agency (NSWA) will be established. The NSWA's objectives will be to support and invest in the social work profession by providing national leadership, and overseeing and supporting social work in the following areas:

• education (pre and post-qualifying)
• improvement (by establishing a Centre of Excellence) and scaling up good practice
• workforce planning
• training and development
• social work terms and conditions (including pay)

These objectives will enable social workers to work more effectively with people to transform their lives and implement rights-based practice.

There will be ongoing collaboration and engagement with the sector, including frontline social workers, on the development of the NSWA. This process will allow further engagement with island communities. The intention is that the NSWA will set national standards that improve social work across Scotland while still allowing flexibility to account for local needs.

As part of the policy development process, there will be further engagement with island communities to consider how to mitigate potential barriers that may undermine the benefits of the NSWA in those communities. In particular, this may include consideration of barriers to training and development opportunities for social workers on islands, such as availability of physical space such as buildings and classrooms and access to online courses; how good practice sharing can take into consideration island demographics, such as smaller communities where people are more likely to know each other and scope for anonymity is reduced; and how workforce planning can take into consideration the unique recruitment and retention issues faced by island communities.

Transfer of functions to the National Care Service

The IRASC's remit was to focus on adult social care, though its report also highlighted the interconnection between adult social care and other areas, particularly children's services and justice social work. Currently, integration authorities are responsible for planning and commissioning a range of health and social care services and one of their purposes is to ensure that these services are planned in an integrated manner so that care is joined up, consistent, and so that resources are more efficiently allocated and duplication is minimised. However, integration of health and social care is inconsistent across Scotland.

Following the Public Bodies (Joint Working) (Scotland) Act 2014, local authorities and Health Boards have integrated health and social care services through the creation of integration authorities. Two models of integration authority are used: an Integration Joint Board (IJB) or a lead agency model. Highland is the only area that has adopted the lead agency model, with all other areas in Scotland establishing the IJB model. Where the Health Board and Local Authority agree to establish an IJB, they must at a minimum delegate to it: adult social care, primary and community adult healthcare services, and unscheduled hospital care for adults. Further services which can be delegated but are not required to be include: children's health services, children's social services, and justice social work. In Highland, where the lead agency model has been adopted, the Health Board is responsible for adult services and the local authority is responsible for children's services.

The following table identifies where services beyond the minimum required have been delegated, with the relevant island IJBs highlighted in bold.

Integration Joint Board	Children's Health Services	Children's Social Services	Justice Social Work	All Acute Services
Argyll and Bute	Delegated	Delegated	Delegated	Delegated
Orkney, North Ayrshire, East Ayrshire, South Ayrshire, West Dunbartonshire, East Dunbartonshire, East Renfrewshire, Glasgow City, Inverclyde	Delegated	Delegated	Delegated	Minimum Services Delegated
Shetland, Eilean Siar, East Lothian	Delegated	Not Delegated	Delegated	Minimum Services Delegated
Dumfries and Galloway	Delegated	Not Delegated	Not Delegated	Delegated
Fife, Renfrewshire, North Lanarkshire, South Lanarkshire, Midlothian	Delegated	Not Delegated	Not Delegated	Minimum Services Delegated
Aberdeen City, Aberdeenshire	Not Delegated	Not Delegated	Delegated	Minimum Services Delegated
Scottish Borders, Clackmannanshire/Stirling, Falkirk, Moray, Edinburgh, Angus, Dundee City, Perth and Kinross, West Lothian	Not Delegated	Not Delegated	Not Delegated	Minimum Services Delegated

In developing the proposals for the NCS, the Scottish Government has sought to continue progress on the integration of health and social care and ensure that existing advanced areas of integration are supported. The NCS consultation sought views on a range of services beyond adult social care, including community health, nursing, children's social work and social care services, justice social work, alcohol and drugs partnerships, mental health, and social care in prisons. Responses to the consultation were broadly supportive of the expanded scope of the NCS, but also raised some specific concerns. Concerns raised by island stakeholders in their responses were similar to non-island communities.

The NCS bill sets out powers for the Scottish Ministers to transfer functions relating to community health, social care, and social work to the NCS by secondary regulation. Details of the functions currently held by local authorities are set out in schedule 3. It covers legislation relating to adult social care, adult support and protection, mental health, alcohol and drugs support, children's social work and social care, and justice social work.

The Bill itself does not transfer any functions. This approach has been taken to permit flexibility for the Scottish Ministers to phase in the transition to the NCS and undertake further consideration and engagement on the decision on inclusion of services beyond adult social care. This will allow the Scottish Government to take stock of existing integration arrangements and plan the transition to the NCS accordingly. The development of regulations to transfer functions from local authorities or Health Boards to the NCS will include further impact assessments to ensure that consideration of how these changes impact on island communities is given due regard.

The Bill also requires Scottish Ministers to consult publicly about any proposed transfer from local authorities relating to children's or justice services using the enabling power before regulations are brought forward. When laying draft regulations to transfer functions, Scottish Ministers must also lay before Parliament a summary of the process by which they consulted in relation to the function transfer and the responses they received to that consultation.

Children's social work and social care services were not considered as part of the IRASC, therefore to fully consider the potential benefits and challenges of locating children's social work and social care services in the NCS, a programme of work will be taken forward to gather evidence on the impact of integration. A crucial aspect of this will be to assess implementation of The Promise in both integrated and non-integrated areas.

Any decision not to transfer children's services to the NCS would also have an impact, as children's services would remain the responsibility of local authorities while adult services would be the responsibility of the Scottish Ministers and the NCS. This could introduce the potential for a disconnect for child to adult transition planning and for whole family support. This would also be subject to further impact assessment to ensure that any such disconnect would be minimised and mitigated.

In relation to the inclusion of justice social work services, flexibility is particularly critical. Justice was not considered as part of the IRASC and any transfer may have significant implications for the statutory model of community justice. The NCS Bill provides flexibility to allow a revised community justice model to be designed with key stakeholders and implemented on a suitable timescale. The policy intention is that a preferred model of delivery will be co-designed with stakeholders, backed by relevant assessment of evidence, and be subject to consultation following a decision to implement the transfer, parliamentary scrutiny and approval before commencement.

One of the key concerns highlighted in the consultation responses from island communities, alongside other responses, was over the need to maintain local accountability of social care services and for local flexibility to ensure that service provision meets community needs. In the development of any regulations to transfer functions to the NCS, careful consideration will be given to these issues to ensure that local accountability and flexibility is maintained. Where functions are transferred to the local care boards, it is intended that these local care boards will be designed to ensure that they are accountable to local people and have the flexibility to provide services in a manner responsive to local needs within an overall national framework that supports them to improve. As set out above, the local care boards are being developed in a co-design process to ensure that they meet this ambition.

Charter of Rights

The NCS Bill places a duty on Scottish Ministers to prepare and publish a National Care Service Charter of Rights and Responsibilities (the NCS Charter). The NCS Charter will provide clarity as to what rights individuals, their families, and their carers can expect and outline clearly the process for complaints should those rights not be met.

The Charter is expected to have a positive impact on people who receive social care services, including in island communities, by providing clarity on their rights in relation to these services and a means for redress should things go wrong. However, it must also be designed carefully to ensure those benefits are also realised for people living in island communities. In particular, the Charter must be both accessible and inclusive and must therefore give consideration to issues around language and internet connectivity.

The development of the Charter will take place through co-design with people with lived and living experience, alongside delivery partners and key stakeholders. That co-design process will involve working with island communities to address any potential barriers. Consideration will also be given to ensure that the co-design process is accessible to those in island communities with lower rates of internet access, including those in more remote areas without broadband and older people who are less likely to use the internet.

Single Point of Access for Complaints

The single point of access for complaints is intended to create a simplified system for people accessing NCS services in relation to complaints about the NCS or local care boards . Scottish Ministers (through the NCS) will have responsibility for establishing and maintaining this system. This system will be designed to operate in addition to and to complement other complaints processes, for example those that exist within organisations or local care boards.

The single point of access will therefore benefit individuals who wish to make complaints, but are unsure of how to make a complaint, and in particular, which body should deal with the complaint. The design of the single point of access system will determine its impact on different island communities. Specifically, the Scottish Government will continue to consider issues of accessibility in terms of connectivity, physical distance, and language as the complaints system is developed.

As with other parts of the NCS, the single point of access for complaints will be part of the co-design process to establish how the NCS will operate. This process will involve island communities to ensure that issues around remoteness, connectivity, and language are taken into consideration to ensure that the complaints process is accessible to all.

Care Records and Information Standards

Scottish Ministers will have a power to set up a statutory scheme through regulations to permit data sharing for the efficient and effective provision of services by, or on behalf of, the NCS and NHS. This is needed to facilitate the creation of a nationally-consistent, integrated and accessible electronic social care and health record which provides a significant opportunity to address the current issues around information sharing, and ensure professionals get timely and accurate information to enable them to safeguard people at risk of harm and provide the highest levels of care. It will also empower people around their own care and data and address the concerns in the IRASC around service users having to tell their story to multiple providers, which is not only frustrating, but can be traumatic. Scottish Ministers will also have the power to set information standards (covering data and digital) which will set out how certain information is to be processed and will be made publicly available. Setting out standards in this way will allow technical detail to be included and to be updated more flexibly as required compared to setting the standards themselves in legislation. Setting information standards is important to improve equality for service users, and also to improve the quality of data used for secondary purposes such as national and regional oversight, planning, commissioning and procurement, regulation, research and national reporting.

The NCS consultation found widespread support for the creation of nationally- consistent, integrated and accessible electronic social care and health record and for proposals that information on social care and health needs should be shared across services.

It is not anticipated that the care records and information standards provisions will have any unique or different impact on island communities than on mainland Scotland. However, decisions on the content of the record are still to be made and there may be unique requirements for people living on the islands in relation to service provision or requirements that do not exist elsewhere. It is also recognised that there may be specific issues related to connectivity, access to services and an ageing population in island communities that may lead to challenges for a digital record (in terms of internet access and digital literacy). This will be considered fully in terms of implementation, particularly for non-digital routes. The record may present the opportunity to analyse data at lower geographical levels and provide better understanding of challenges and requirements for those living on more remote islands, or those living on islands where the local authority is not an island-only local authority (as these islands are often represented at local authority level which may not truly reflect their unique situations).

Ethical Commissioning

The NCS Bill sets out the remit for the Scottish Ministers to develop and manage a National Commissioning and Procurement Structure of Standards and Processes for ethical commissioning and procurement (referred to here as "a framework for ethical commissioning" or just "ethical commissioning"). These standards will ensure a consistent approach to the way commissioning and procurement delivers a person centred, human rights based approach that supports the outcomes and needs of the individual, meets minimum quality standards established for social care services, ensures fair work, promotes sustainability, and ensures consistent implementation and equitable quality of service throughout Scotland. The Bill sets outs that local care boards will be responsible for developing an ethical commissioning strategy as part of their Strategic Plan. The NCS will be responsible for governance and assuring local care boards comply with the Structure of Standards and Processes of ethical commissioning, through oversight and approval of their Strategic Plans.

The role of NCS is expected to include the ethical commissioning of care services on a national basis. Ethical commissioning and procurement standards will allow the Scottish Government to focus on those important issues that will affect how care is planned, designed, sourced, delivered, and monitored. It will allow the Scottish Government to spotlight critical areas that are reserved to the UK Government where there are limited legislative levers and enable us to take action through NCS accountability and governance structures. Ethical standards will ensure the Scottish Government values and recognises the workforce by developing minimum fair work standards, terms and conditions and will contribute to climate resilience/climate change adaptation in future by taking account of the irreversible impacts of climate change.

In developing the framework for ethical commissioning, further engagement with stakeholders, including island communities, will be undertaken to assess the impact of these proposals as they are developed. That will include consideration of the framework for ethical commissioning in localities where the majority of provision of social care services is provided in-house by local authorities, such as in Na h-Eileanan Siar, Orkney Islands, and Shetland Islands, and how to support the continued mix of delivery in the island communities.

As part of its role around commissioning, the NCS will also be responsible for market oversight and shaping as part of its strategic planning. This role will be focused on ensuring that there is capacity within the social care system to meet demand by conducting market research, analysis, and oversight and working in conjunction with the Care Inspectorate and local care boards to understand the state of the social care system. The NCS will work closely with public, independent and third sector providers both nationally and locally to ensure a proactive and long term approach to social care provision. As this function is developed, its impact on island communities based on their local approaches to social care provision will be assessed.

The Bill also provides the facility or contracting authorities to reserve procurement processes for certain voluntary and third sector mutual organisations. This provision will allow organisations that have a history and expertise in providing community health and social care services and support and are a major part of the social care market to more easily access contracts. The details of the scope and definition of mutual organisations will be established in regulation following further consultation with stakeholders.

Breaks from Caring

Breaks from caring responsibilities are key to looking after carers' own health and wellbeing and their lives beyond caring. Currently, all unpaid carers have the right to an adult support plan or young carer statement to identify what is important to them and their needs for support. This can include identifying their need for breaks from caring and support from their local authority to access those breaks. The Bill proposes a statutory right for unpaid carers to breaks from caring in order to ensure that all unpaid carers with an identified need for breaks are able to access them.

By establishing a statutory right to breaks, the Bill aims to improve access to breaks from caring to unpaid carers across Scotland and so will have a positive impact. However, island communities can face additional barriers when accessing some breaks, which can arise from difficulties accessing replacement care due to staff availability and transport costs and availability when travelling to and from services. By integrating the right to breaks from caring into Carers Act rights to adult support plans and young carer statements, the process should allow barriers individual carers face to be identified and enable personalised support to suit their needs.

To ensure access to breaks from caring in practice, including overcoming unique barriers in island communities, the Scottish Government provides a Short Breaks Fund. The fund was £3 million per year up to 2021-22 and has been increased by £5 million in 2022-23 to expand easy-access short breaks support. Under this fund, the Time To Live and Take a Break Scotland grants and the Creative Break and Better Break projects are delivered. In addition to the Short Break Fund, the Promoting Variety in Short Breaks project, run by Shared Care Scotland and Health Improvement Scotland, helps local authorities and integration authorities meet their responsibility to promote availability of different short break support services in their areas. These grants and projects take into consideration the additional costs of providing breaks to carers in rural and island communities and are designed to ensure the flexibility and creativity necessary are in place to ensure access to breaks from caring.

Anne's Law

Social connections and meaningful activity are vital for the wellbeing and quality of life of people living in a care home. Families and friends play an essential role in the health and wellbeing of people who live there, in terms of both practical and emotional support. For many residents, family members or friends also play a vital role in their care, complementing the support provided by care home staff. The Coronavirus pandemic has led to periods where care home residents and residents in adult social care settings were unable to receive visitors during lockdowns and outbreaks. These restrictions on visits during the lockdown periods are acknowledged to have negatively impacted the health and wellbeing of people living in care homes and their friends and family.

The NCS Bill provides for the Scottish Ministers to issue Directions to care home providers about social visits to residents in their accommodation. The objective is to ensure that providers and public health teams give effect to visiting rights and to remove variation in practice in the sector including the use of blanket visiting bans. In practice, this will mean that rights are underpinned by statute, so that visiting will always be supported in line with Directions issued from Scottish Ministers. These provisions have been widely welcomed by stakeholders and are expected to have a positive impact on visitation rights by providing a clear mechanism for Ministers to set out requirements. No specific issues with regards to island communities have been identified but this is being kept under review.

Regulation

The Scottish Government is already responsible for the regulation of social care services and the social care workforce. The Care Inspectorate (formally known as Social Care and Social Work Improvement Scotland) is responsible for registration, inspection, complaints investigation, and enforcement in relation to social care providers.

The Bill introduces new powers to strengthen enforcement action by the Care Inspectorate in order to enable the regulator to swiftly take action with poor performing services, better protect social care users, and drive up the consistency and quality of care expected across all social care services in Scotland. The focus of any enforcement action is always on the experiences, wellbeing and outcomes for people who use services. The new powers include:

• To set out further criteria to determine when the Care Inspectorate might propose to cancel a service's registration, including on the basis of previous enforcement action;
• Additional joint inspection powers to enable the Healthcare Improvement Scotland (HIS) and the Care Inspectorate to carry out joint inspections in relation to clinical care practice advice and infection prevention and control advice;

The impact of these changes is to improve enforcement action by the Care Inspectorate to raise standards of social care services. These powers have been designed with the sustainability of care services within rural communities in mind. They have balanced enabling effective regulation of care services while allowing flexibility and proportionality to account for local needs and ensuring that rural areas and islands are not negatively impacted.

Reporting and Monitoring

The Bill sets out the overall principles that Scottish Ministers and the local care boards must work within when delivering services within the scope of the NCS. It also requires both Scottish Ministers and the local care boards to consult on and produce strategic plans and ethical commissioning strategies for the delivery of community health and social care. Through these plans, Parliament and the public will be able scrutinise the activities of the NCS and hold Scottish Ministers and the NCS to account for the way the NCS principles are put into practice.

The Bill also sets out that Scottish Ministers will be responsible for monitoring and improve the quality of community health and social care services provided to people. This will involve the setting of standards and frameworks at national level and the effective use of data, evidence and lived experience to make sure that the national standards and expectations are being met. Local care boards will also be expected to make effective use of lived experience, data, and evidence to make sure they are continuously improving services at local level. The NCS will take a collaborative approach to driving improvement through effective use of lived experience, data and evidence to identify good practice and collaborative leadership to support good practice to be adopted right through the system. By taking this approach, the experiences of social care in island communities can be taken into consideration by the local care boards responsible for those communities.

Scottish Ministers will also have an important role to monitor the performance of the local care boards. It is anticipated that this will be done administratively in the same way that Ministers oversee the performance of Health Boards. However, the Bill enables Scottish Ministers to take steps to address poor performance by the local care boards through the ability to set legally binding Directions to them. In extreme cases, Ministers can abolish a Board and ask another board or another body to take over their functions.