A National Care Service for Scotland: consultation

Improving care for people

BSL version of Chapter 1: Improving Care for People

The case for change

We need to improve community health and social care support for those who rely on it, and for unpaid carers, and those who work in it. More of us each year are needing or seeking to access community health and social care support, or are helping others who need access. These services are core to supporting the health and wellbeing of the population, to enable everyone in Scotland to thrive. They must be a springboard not a safety net. Developing a system that delivers consistent and fair access to care and support services across the country and improves outcomes for people is a priority. Making Scottish Ministers accountable for social care will help to achieve that consistency and drive forward improvement.

Creating this improved system, one that works for people, will require every one of us to work together, placing the interests of the person at the centre of our decision making.

This chapter covers proposals that look to transform the system, put a human rights based approach at its heart and strengthen the focus on preventative approaches across community health and social care services.

Improvement

How it works now

Despite improvement methodology and implementation science being widely used and embedded in social care practice, we have yet to see the impact of large-scale evidence based improvement work in the integrated world of health and social care.

Nationally there are several organisations that advocate, practice and advise on improvement including CELCIS (Centre for Excellence for Children's Care and Protection), IRISS (Institute for Research and Innovation in Social Services), HIS (Healthcare Improvement Scotland – ihub) and CYPIC (Children and Young People Improvement Collaborative). The Care Inspectorate also supports improvement alongside its primary role of scrutiny and inspection. The Improvement Service provides improvement support to Local Government.

Yet we have not been able to consistently scale up good practice – partly due to lack of investment but also due to the many complexities of different professional governance and regulation structures, multi-agency working and the different cultures that underpin practice across the sectors.

The establishment of the National Care Service (NCS), accountable to Scottish Ministers, is an opportunity to consider how better to align the proven successful elements of improvement methodology and implementation science - to provide a model that practitioners at all levels can implement as a whole rather than a sum of the parts. To do so, there is merit in reviewing the services delivering improvement in Scotland and consider the most efficient method to deliver this for community health and social care.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 27: A National Improvement Programme for social care, along the lines of the NHS Patient Safety Programme, should be introduced by the National Care Service, and should address the three following key areas:

• The experience and implementation of self-directed support must be improved, placing people using services' needs, rights and preferences at the heart of the decision making process.
• The safety and quality of care provided in care homes must be improved to guarantee consistent, appropriate standards of care.
• Commissioning and procurement processes must be improved in order to provide a vehicle for raising the quality of social care support and for enhancing the conditions and experience of the social care workforce.

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

What we propose

Improvement must be a key focus of the NCS. The establishment of a single national body, with clear lines of accountability to Ministers at a national level, gives us the opportunity to ensure that consistent, high standards of performance are developed and maintained across Scotland. That national view will also ensure that learning can be shared and implemented across the country. Intelligence gained from inspection and scrutiny of services will be used to identify where improvement is needed, and themes will be fed back into commissioning and procurement.

Questions

Q1. What would be the benefits of the National Care Service taking responsibility for improvement across community health and care services? (Please tick all that apply)

BSL Version of Question 1

• Better co-ordination of work across different improvement organisations
• Effective sharing of learning across Scotland
• Intelligence from regulatory work fed back into a cycle of continuous improvement
• More consistent outcomes for people accessing care and support across Scotland
• Other – please explain below

Q2. Are there any risks from the National Care Service taking responsibility for improvement across community health and care services?

BSL Version of Question 2

Access to Care and Support

How it works now

Where it is identified that a person may have a social care need, their local authority's social work department has a legal duty to undertake or organise an assessment. This is mandated by the 1968 Social Work Act (section 12A), which obliges local authorities to "decide […] whether the needs of the person being assessed call for the provision of any [community care] services".

This assessment is a care management process, in which a care professional meets with an individual to explore and observe their support needs. It should also include investigating their existing care arrangements, strengths, and hopes in order to inform decisions about meeting their needs. The assessment should include discussions with the individual and their support network to discuss how the person's needs can best be met and how they would like their care and support delivered.

A person's access to care and support is determined by their eligibility, according to National Standard Eligibility Criteria. These criteria are descriptions which categorise the care needs of individuals, which are currently defined as: 'critical', 'substantial', 'moderate', or 'low'.

People who are not at critical or substantial risk may still have needs for some personal care or other social care support. Local authorities are expected to have in place arrangements for meeting, managing, and reviewing these needs. This may involve providing or referring to preventative or other support services, including providing advice about alternative sources of support or setting a clear timescale for reviewing the person's needs.

Where individuals have critical and substantial needs, and high levels of risk or public protection issues arise, this requires a Social Worker to carry out a risk management assessment and develop a care plan. The care planning will be led by the Social Worker and sets out how the complex care needs will be managed and co-ordinated and risk mitigated. This level of care planning will require input from a range of agencies and professionals and a high level of professional judgement.

In certain circumstances because of the levels of risk to the individual this will also require the Social Worker to use statutory powers to support and protect the individual

The Social Care (Self-directed Support) (Scotland) Act 2013 was introduced as a way of providing support that means people are given choice and control over how their care and support can be delivered. It means that people can choose and arrange some or all of their own support instead of having it chosen and arranged by other people. Implementation across Scotland has been variable and a new Framework of Standards to support Self-directed Support (SDS) was recently published.

Different arrangements apply to support for unpaid carers. All unpaid carers (regardless of their caring role) have rights to an outcomes-focused support plan to look at their caring situation, identify what is important to them and their needs for support. Eligibility criteria for carer support must be set locally to determine which needs are eligible for support. All carers have rights to information and advice relevant to their caring role and most areas have preventative support open to all carers such as activity groups or peer support.

Since 2011, the Scottish Government has funded a network of independent support organisations to provide, advice and advocacy to help people understand their rights to social care and to support them to access the care that is right for them. The current Support in the Right Direction Programme funds 31 projects covering all but one of the local authority areas. They provide advice and help with pre-assessment to understand the SDS process, help people identify their personal outcomes and develop support plans, and provide coaching, advocacy, and peer support for people accessing care and support. They aim to provide an "end to end" service for people throughout their journey through social care and they can work with families and unpaid carers as well as people accessing support.

The Public Bodies (Joint Working) (Scotland) Act 2014 created Integration Authorities which are accountable for the planning of health and social care services. Health and Social Care Partnerships represent the delivery of these integrated community health and social care by integrated teams. All adult social care is delegated to Integration Authorities, and around a third of Integration Authorities also have delegated responsibility for children and families. Around half have a delegated responsibility for justice social work.

The Independent Living Fund (ILF) was established in 2015, following the closure of a UK Government programme, and is effectively a national scheme of direct payments to support independent living by disabled people. The Independent Review of Adult Social Care (IRASC) called for ILF to be re-opened. We will consider options for the future of the ILF within the context of the development of the National Care Service.

Whilst the IRASC acknowledges there is already much good practice, there is a gap between what is intended by the existing legislation and frameworks and what is actually delivered, with too much variation in outcomes between different parts of the country.

Issues and problems

The IRASC highlighted a number of issues with the current provision of adult social care. Too often, adults and their families can be excluded from assessment and support processes by complex bureaucracy. The IRASC labels eligibility criteria a 'barrier to accessing care', with supported people describing a 'maze of benefits'. People report that the system is complex and challenging to navigate, and that the support received depends on where they live.

The organisation of services, with different professionals and agencies, often seems overwhelming for those seeking support. Supported people responding to the IRASC called assessments "intrusive, not focused on rights or equality, not focused on assets or potential but on deficits, reduced to identifying care tasks, and always overly focused on eligibility, which was frequently set at 'critical needs', and costs" and stated "there are too many times that adults are expected to repeat those worst moments of their life, including at annual reviews, to 'justify' the services provided to them."

For many the current experience for adults and their unpaid carers can be summarised as follows:

• A complex system that is difficult for people to negotiate.
• Lack of a consistent point of contact to speak to or liaise with.
• Lack of consistency across the country in what people can access (the postcode lottery).
• Lack of "portability" of care packages/plans if people need to move around the country.
• Application of eligibility criteria.
• Lack of a national practice model that will provide a single planning process.
• No single adult's plan or pathway.
• A system that is not flexible to reflect changing needs.
• A system which focuses on acute and crisis support rather than prevention and early intervention.
• People having to tell their story over and over again.

The IRASC recognised the importance of independent support and brokerage services such as the Support in the Right Direction projects, which make people aware of their choices and possibilities across the SDS options and to support them to ensure the process of arranging and receiving care is co-produced. It says that not enough of these services are available and there is not enough awareness of them.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 1: Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded. This could be further enabled by the incorporation of human rights conventions.

Recommendation 3: People must be able to access support at the point they feel they need it, including for advice and signposting to local community-based resources and help, and for barriers to this, such as the current eligibility criteria and charging regime, to be fundamentally reformed and removed, to allow a greater emphasis on prevention and early intervention.

Recommendation 4: People should understand better what their rights are to social care and supports, and "duty bearers", primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.

Recommendation 6: Informal, community based services and supports must be encouraged, and funded to respond appropriately to the needs of local citizens, including for preventative and low level support.

Recommendation 7: A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people's heads and must enable a full exploration of all self-directed support options that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical.

Recommendation 8: More independent advocacy and brokerage services, including peer services, must be made available to people to ensure that their voices are heard, and to help prepare for participation in planning and organising their support.

Recommendation 10: Packages of care and support plans must be made more portable and supported people should not have to fight to retain support because they have moved home.

Recommendation 31: Investment in alternative social care support models should prioritise approaches that enable people to stay in their own homes and communities, to maintain and develop rich social connections and to exercise as much autonomy as possible in decisions about their lives.

Recommendation 39: A decisive and progressive move away from time and task and defined services must be made at pace to commissioning based on quality and purpose of care – focused upon supporting people to achieve their outcomes, to have a good life and reach their potential, including taking part in civic life as they themselves determine.

Recommendation 51: Re-open the Independent Living Fund, with the threshold sum for entry to the new scheme reviewed and adjusted.

What we propose

The creation of a National Care Service, accountable to Scottish Ministers, provides an opportunity to deliver transformational change to the way care and support is delivered to adults in Scotland. We will remove eligibility criteria in their current form by moving away from a focus on risk and instead focusing on enabling people to access the care and support that they need to lead a full life. This will mean significantly changing the way care and support services are designed, so that prevention and early intervention is prioritised and people can move easily between different types of care and support as their needs change.

Public services are often thought of as a pyramid. Universal services, which are engaged with by the majority of people, are at the base of the pyramid, while specialist services which are only required by a minority of people are at the top.

In health, for example, GPs and community healthcare teams provide a combination of universal and targeted services, while hospitals provide more specialist services.

In adult social care, the majority of services currently provided are at the top end of the pyramid of services. That means that people who need targeted and universal services often either are not able to access support or have to use specialist services instead, meaning that they do not get the early support they need and putting more pressure on specialist services.

The approach to care and support being proposed as part of the National Care Service will involve designing and implementing consistent care and support services at all levels of the pyramid. This will allow support planning to focus on which type of support people need, rather than a decision between getting support or getting no support.

We will increase the number of care and support services which focus on prevention and early intervention, including community based services which can be accessed without a referral or full assessment. These will be at the heart of a Getting it Right for Everyone approach to care and support, and will work seamlessly with services for people with more complex care needs. We will set this new approach to care and support out in legislation, to ensure that there is not a postcode lottery and to support the portability of care.

The National Care Service will have a clear focus on positive outcomes for people and Getting it Right for Everyone. It will involve the people of Scotland in the design, development, and delivery of support and services from the outset and on a continual basis. It will define the strategic direction, quality standards, and the framework for person-centred operational delivery of community health and social care in Scotland, working in concert with the NHS, local authorities, and the third and independent sectors to plan, commission, and deliver the support and services that the people of Scotland require.

Care and Support Services

We propose that there will be a single approach to care and support services covering all types of care and support from early intervention to specialist intervention. This will be applicable to all settings, including prisons and places of detention, and will include:

• More support and services addressing early intervention and prevention, for example open access and community based provision.
• Join up between advice, support, and care services, to enable people to easily move between different types of care and support.
• A single model which eliminates variations in practice, but with flexibility of delivery approach depending on geography and need.

Getting it Right for Everyone

Drawing on the success of the "Getting It Right For Every Child (GIRFEC)" multi-agency approach, we want to develop a GIRFE National Practice Model: Getting It Right for Everyone. This is a pathway through support and services from young adulthood to end of life care. GIRFE will help define the adult's journey through individualised support and services, and will respect the role that everyone involved has in providing support planning and support. Too often, adults and their families are excluded from assessment and support processes by complex bureaucracy. GIRFE is about providing an easier way to access help and support when it is needed - recognising the crucial value of working alongside and with adults and their families, in seeking to achieve the best outcomes for them.

The practice model will define how people, communities, and services, identified as necessary to deliver support to the adult, get involved as early as possible and where appropriate throughout the delivery process, to ensure that support is provided quickly and without unnecessary bureaucracy – with the adult's wishes at the centre of the process. The key aim of this approach is to ensure that support and services cluster round individuals and families to ensure their needs are met, rather than working in silos, mirroring the GIRFEC approach.

GIRFE will provide a model that uses the same language to describe and assess an adult's strengths and needs, and with common practice tools across professional groups. It will include everyone who requires support including younger adults transitioning from Children's Services, adults vulnerable to exploitation or abuse, adults within the justice system in the community and following discharge from prison, and older adults who are experiencing or at risk of physical or mental frailty.

Support Planning

A critical aspect of the new approach is a single adult's plan and a single planning process. This will cover all aspects of care planning from the point that it's identified that care and support may be needed, through to agreement of the care and support to be provided and beyond. This should:

• Be rights based, based on the relationships that are important to the adult, and relentlessly focused on putting the adult at the centre of decision making and improving outcomes with them and for them.
• Feature a strengths-based support planning process, which enables the person to manage their own care as far as possible.
• Include options for both light touch and more detailed support planning, depending on the level of complexity and need, as part of a single planning process and model of care. Linked to the development of an integrated social care and health record, to ensure that, with their consent, people's information moves through the system with them.
• Provide a No Wrong Door approach to access to care and support, so that people only have to enter services once, and are supported within a coordinated system of support.

Questions

These questions ask about accessing care and support and the support planning process. We want to know your opinions on how things should work in the future, under a National Care Service, rather than about how they work now. When you are thinking about these questions, you could reply for yourself or thinking about someone you know, for example a friend, a family member, or someone who you provide unpaid care for.

Accessing care and support

Social care support is accessed by a wide range of people with diverse needs at different points in their lives, including older people; children, young people, and families; people living with disabilities; people with learning disabilities, short or long term mental health concerns, dementia, sensory impairment, complex disabilities, acquired brain or spinal injury, epilepsy, or people experiencing difficulties in relation to alcohol and other drug use; people who are homeless, or at risk of homelessness; and survivors of domestic abuse or gender based violence. It can include lots of different types of support and services, from advice, to someone coming into your home to provide care, or residential care.

Q3. If you or someone you know needed to access care and support, how likely would you be to use the following routes if they were available?

BSL Version of Question 3

Speaking to my GP or another health professional.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Speaking to someone at a voluntary sector organisation, for example my local carer centre, befriending service or another organisation.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Speaking to someone at another public sector organisation, e.g. Social Security Scotland

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Going along to a drop in service in a building in my local community, for example a community centre or cafe, either with or without an appointment.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Through a contact centre run by my local authority, either in person or over the phone.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Contacting my local authority by email or through their website.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Using a website or online form that can be used by anyone in Scotland.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Through a national helpline that I can contact 7 days a week.

• Not at all likely
• Unlikely
• Neither likely nor unlikely
• Likely
• Very likely

Other – Please explain what option you would add

Q4. How can we better co-ordinate care and support (indicate order of preference)?

BSL Version of Question 4

Have a lead professional to coordinate care and support for each individual. The lead professional would co-ordinate all the professionals involved in the adult's care and support.

Have a professional as a clear single point of contact for adults accessing care and support services. The single point of contact would be responsible for communicating with the adult receiving care and support on behalf of all the professionals involved in their care, but would not have as significant a role in coordinating their care and support.

Have community or voluntary sector organisations, based locally, which act as a single point of contact. These organisations would advocate on behalf of the adult accessing care and support and communicate with the professionals involved in their care on their behalf when needed.

Support planning

The following questions are about the support planning process, which is sometimes referred to as an assessment. This is the process of collecting information about you and your life, and having a conversation with you about your strengths, your support needs, and the type of care and/or support you would like to get. It is used to agree what care and support services you should be able to access.

We are interested in your views on how support planning should work in a National Care Service. You could answer this thinking about care and support services that you use now or may want to use in the future, or for a friend, family member, or someone you provide unpaid care for.

Q5. How should support planning take place in the National Care Service? For each of the elements below, please select to what extent you agree or disagree with each option:

BSL Version of Question 5

a. How you tell people about your support needs

Support planning should include the opportunity for me and/or my family and unpaid carers to contribute.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

If I want to, I should be able to get support from a voluntary sector organisation or an organisation in my community, to help me set out what I want as part of my support planning.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

b. What a support plan should focus on:

Decisions about the support I get should be based on the judgement of the professional working with me, taking into account my views.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

Decisions about the support I get should be focused on the tasks I need to carry out each day to be able to take care of myself and live a full life.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

Decisions about the support I get should be focused on the outcomes I want to achieve to live a full life.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

c. Whether the support planning process should be different, depending on the level of support you need:

I should get a light-touch conversation if I need a little bit of support; or a more detailed conversation with a qualified social worker if my support needs are more complex.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

If I need a little bit of support, a light-touch conversation could be done by someone in the community such as a support worker or someone from a voluntary sector organisation.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

However much support I need, the conversation should be the same.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

Light touch and/or more detailed support planning should take place in another way – please say how below

Q6. The Getting It Right For Everyone National Practice model would use the same language across all services and professionals to describe and assess your strengths and needs. Do you agree or disagree with this approach?

BSL Version of Question 6

• Agree
• Disagree

Please say why.

Q7. The Getting It Right for Everyone National Practice model would be a single planning process involving everyone who is involved with your care and support, with a single plan that involves me in agreeing the support I require. This would be supported by an integrated social care and health record, so that my information moves through care and support services with me. Do you agree or disagree with this approach?

BSL Version of Question 7

• Agree
• Disagree

Please say why.

Q8. Do you agree or disagree that a National Practice Model for adults would improve outcomes?

BSL Version of Question 8

• Agree
• Disagree

Please say why.

Right to breaks from caring

How it works now

Breaks from caring are a vital element of carer support. We use the term 'carer' to mean someone providing unpaid care for another person so it does not include members of the paid social care workforce. The full legal definition of carer is in section 1 of the Carers (Scotland) Act 2016 ("Carers Act").

The term 'respite' (as used in the Independent Review of Adult Social Care (IRASC)) is not defined or used in legislation but usually refers to support which enables a carer to have a break. The duration can vary from a few hours to a week or more. It can involve support at home, the cared-for person visiting a day service or residential setting, or a holiday break for both parties. It often includes support for the cared for person to replace what the carer usually provides. It can also incorporate support for the carer to achieve what matters to them like participating in a sport or hobby, or seeing friends.

While the term 'respite' is widely understood, it is contested as implying a burden or negative representation of the relationship in which care takes place. This document therefore refers to 'breaks from caring' or 'short breaks'.

The Carers Act gives carers the right to support to meet their eligible needs. The Carers Act does not use the term respite and does not create an automatic right to breaks. Instead it requires the need for a 'break from caring' to be considered as part of carers' wider rights to support. Under the Carers Act:

• All carers have the right to an adult carer support plan or young carer statement to identify their personal outcomes and needs for support.
• If any (or all) of these 'identified needs' meet the local eligibility criteria, the carer has the right to support to meet such 'eligible needs'. This can either be support for the carer or the cared for person.
• The authority can also decide to provide support where the identified needs do not meet local eligibility criteria.
• Carers have the right to choose how any such support is provided, in line with the options for self-directed support.
• Whenever an authority is providing support to meet a carer's identified needs, it must consider whether that support should include a break from caring.

Alongside statutory support under the Carers Act, the Scottish Government also funds the £3 million per year voluntary sector Short Breaks Fund. The Time to Live element of this fund allows local carer centres to offer small grants for unpaid carers to spend on something that gives them a break. These grants provide preventative level support, mainly to carers who do not receive more extensive statutory short break support, to help them recharge - improving their resilience and helping prevent caring relationships breaking down. They have the advantage of reaching carers who may not yet want or need to be in contact with the wider social care system or to prepare a full adult carer support plan or young carer statement. The grants are personalised through discussion with local carer centres about what the carer needs.

Issues and problems

Despite the above rights, relatively few unpaid carers (around 3%) receive statutory support for breaks from caring. This support is often expensive and local authority and Health and Social Care Partnership (HSCP) local eligibility criteria are generally set at high levels of need, to help manage budget pressures.

There were 700,000 – 800,000 unpaid carers before the pandemic, and potentially over 1 million during the pandemic. Caring roles vary in nature and intensity so, while all carers need to be able to take a break, they may not all need the same support to achieve that. It is important that a right to breaks from caring recognises this.

Before the pandemic, there were problems with lack of availability of short break facilities for people with complex or high level support needs.

During the pandemic, there have been problems with availability of many services which enable breaks, particularly day centres and short breaks in care homes.

Relevant Independent Review of Adult Social Care Recommendation

Recommendation 11: Carers need better, more consistent support to carry out their caring role well and to take a break from caring with regular access to quality respite provision. Carers should be given a right to respite with an amendment to the Carers Act as required, and a range of options for respite and short breaks should be developed.

What we propose

The proposed right to breaks from caring will function as a part of the wider social care support system. We want it to be one element of plans to create a single, outcomes-focused approach to care and support which stretches from prevention and early intervention through to acute and specialist provision.

To achieve this, there are several important factors to consider in designing a right to breaks from caring, such as fairness, personalisation, transparency and the value of preventative support. We have considered options which strike different balances between these factors.

Preventative support versus acute need

A right to breaks from caring needs to balance the need for preventative support for a wide group of carers and more intensive support to meet the needs of a smaller group of carers who need it. Both aspects are important for carer wellbeing. It is equally important that short break support achieves positive outcomes for those with care needs (the cared-for person). Preventative support will help to stop many carers and cared-for people reaching crisis point – improving their resilience. But it will never wholly eradicate the need for more intensive support at some stage in many caring journeys. Our preference is a right to breaks from caring which is capable of meeting needs for preventative support as well as needs for more intensive support.

Standard support packages versus personalised support

A right to breaks from caring could be expressed as a right to a standard support package or as a right to personalised support to meet need. Each of these can be viewed as fair or unfair, depending on how fairness is determined.

An entitlement to a standard support package would ensure all qualifying carers were entitled to the same thing. The entitlement could be expressed in terms of days or weeks of short break support or in financial terms. A standard entitlement expressed in financial terms could disadvantage carers of people with more complex health and care needs because replacement care would be more expensive. However, every caring situation is different and a standard package of support may not enable a carer to achieve what matters to them. A lower standard level of support would fail to meet the needs of carers in more intensive and complex caring roles. A very high standard level of support (set at the most acute level of need) would be disproportionate for most carers and unlikely to be affordable. No flat rate entitlement could be fully consistent with the aim of personalising support to deliver personal outcomes.

A tailored entitlement to personalised short break support to meet need would result in different carers receiving different support. But it would be fairer in terms of wellbeing and would better support the needs of both those requiring lower level preventative support and those in intensive and complex roles.

The starting assumption in the Independent Review of Adult Social Care (IRASC) is that any new right to breaks from caring would be integrated into carers' rights under the Carers Act. The Act already creates a structure for discussing each carer's personal outcomes and broader support needs and rights. It would be possible to ensure personalisation by following the IRASC recommendation to integrate a new right to breaks from caring into the Carers Act.

A right for all carers versus thresholds for accessing support

A right to breaks from caring could apply to all carers or only to those who meet a threshold in terms of hours or intensity of caring. The options here look different in terms of outcomes and affordability, depending whether the right is to a standard package or to personalised support.

A right for every carer to a standard package of support may be initially appealing. Given the numbers of people involved (around 1 million), affordability constraints would be likely to mean this is a more modest entitlement, which could not meet the needs of carers in more intensive roles.

Alternatively, a threshold could be set to enable a smaller number of carers to access a larger standard package of support. This would not deliver the preventative support element. It would also exclude carers in less intensive caring roles who may nonetheless be unable to take a break. These issues could be mitigated by setting a series of thresholds to access a series of set packages of support. This would refine the system but would not deliver fully personalised support.

A right for every carer to personalised support to meet need would enable different levels of need to be supported without excluding any set of carers and without setting thresholds. This would also be in line with the existing approach in the Carers Act, which deliberately moved away from the old threshold of "regular and substantial" caring before a carer could access support, and would be in line with our proposed future approach to accessing support generally.

Transparency and Certainty versus Responsiveness and Flexibility

A right for every carer to a standard package of short break support would be very transparent, providing certainty for carers and authorities about what carers are entitled to. But it would be neither flexible nor responsive to individual need and would not deliver personalised support or fairness in terms of outcomes.

A right to personalised support would be more flexible and responsive and would involve the carer in identifying outcomes and scoping the support needed. But this process implies less transparency and certainty on the face of legislation about exactly what support each individual carer will receive. It would therefore be important for the personalisation process to deliver certainty for individual carers about the short break support they are entitled to and for this to be consistently applied across the country.

Verification and support planning

Every option will require some kind of verification and support planning process in order to access support under a right to breaks from caring. All options require some engagement with the carer about their caring situation. Options which involve a threshold of caring hours to qualify for the right require a way of establishing whether the carer meets the threshold. Options which involve personalised support require discussion with the carer to identify what support is needed. The key issue is ensuring that these processes are person-centred, proportionate and carer friendly.

Under the Carers Act, these processes are intended to work on an informal and person-centred basis through engagement with carer centres and through discussion when preparing an adult carer support plan or young carer statement. The existing Time to Live grant model also offers a light touch means for accessing and personalising non-statutory support for breaks. However, this might end up looking very like a Carers Act process if it were converted into a statutory entitlement.

Options

Group A options – Rights to standard short break packages

a. A universal flat rate entitlement could entitle all carers to a flat rate entitlement to a standard short break package (expressed in number of hours/weeks or in financial terms).

b. A flat rate entitlement restricted to carers who cannot otherwise get a regular break from caring due to the intensity of the caring role. This might be based on hours of caring (e.g. 20+ hours per week; 35+ hours per week; 50+ hours per week) or more sophisticated nationally set criteria covering people in less predictable caring situations. Restricting to a smaller group may enable a more generous flat rate entitlement than an entitlement for all carers.

c. Both of the above approaches could be refined by having a graded level of break entitlement increasing (possibly in steps) according to intensity of the caring role. Again, the level of intensity might be measured on the basis of hours caring (e.g. a basic entitlement for those caring under 20 hours per week; a medium entitlement for those caring 20-35 hours; etc.) or some more sophisticated nationally set graded criteria.

d. A standard entitlement for all carers who have a break from caring identified among their support needs as part of their adult carer support plan or young carer statement. The level of the standard entitlement could vary according to the intensity of caring as in (c). In this model, the adult carer support plan or young carer statement would identify an entitlement to a break but the support provided could still be standardised in some way.

A standard entitlement would be transparent but has limitations for the following reasons. A universal flat rate as in (a) would either underprovide for those in greatest need or overprovide for those with less intense caring roles. A flat rate with a threshold for who the right applies to as in (b) would be inconsistent with the aims of the Carers Act to recognise that the impact of caring is not solely linked to hours of caring and to deliver personalised support, based on what matters to each carer. This option would also exclude carers with less intense caring roles, whether or not those roles have a significant impact on wellbeing or prevent them taking breaks. A graded series of entitlements as in (c) would go some way to matching the level of support to need but would still lack personalisation. The approach in (d) would go through the person-centred processes in the Carers Act to identify personal outcomes and personal needs but would then ignore those to deliver a standard package rather than personalising support.

Group B options – Rights to personalised support

e. A right to personalised support wherever the need for a break from caring is identified as part of the carer's adult carer support plan or young carer statement. This would be a personalised entitlement to meet the carer's specific needs as identified in their individual plan under the Carers Act. Subject to wider decisions on the approach discussed at the Access to Care and Support section of this consultation, this right could apply without additional criteria for who it applies to.

f. Option (e) could be strengthened by the following provisions:

• A statement of principle that every carer is entitled to have sufficient rest and regular breaks from caring. Consideration could be given to whether this should refer to a certain number of days or weeks break from caring.
• A new duty to consider whether this entitlement is being achieved when identifying the personal outcomes for every carer as part of an adult carer support plan or young carer statement.
• If a carer is not achieving this entitlement then their identified personal needs must include a need for support to achieve sufficient rest and regular breaks from caring.

This would then connect to the existing Carers Act duty to provide support to meet these needs. Option (f) would have the advantage of establishing universal statutory recognition that all carers need a break while retaining scope to personalise the support required to meet the need in each case.

It would create a statutory expectation that all carers should have a level of time off. It could be used to set a standard expectation about how many days or weeks break people need.

It would ensure that all carers who do not currently have sufficient time off can have their needs for breaks identified through the existing adult carer support plan or young carer statement process in the Carers Act. It would do this by ensuring breaks are considered at an earlier stage and are always a key personal outcome and need for every carer. These outcomes and needs for breaks would then be captured in every carer's adult carer support plan or young carer statement and would flow through to the duty on authorities to provide support under the Act.

It would also provide a way to target investment to maximise benefits for carers by ensuring that support is personalised to meet what each carer needs to achieve their breaks outcomes. The support needed may vary, with some carers needing significant replacement care, while others may need lower levels of preventative support for their own break.

Group C options – Hybrid approaches

We are considering whether it is possible to establish a hybrid approach, combining:

• a smaller, guaranteed minimum flat-rate entitlement (as options (a) or (b)) which is easier to access for those in less intensive caring roles; and
• a more personalised entitlement, based on identified needs (as options (e) and (f)) for those in more intensive caring roles.

This has potential to target investment to maximise the benefits in terms of improving outcomes and protecting wellbeing for carers by combining preventative support alongside support for those with higher levels of need.

Such an approach would still require criteria for which carers could access the two elements and consideration would need to be given to whether it was workable, affordable, or proportionate to legislate for two different approaches to entitlement.

An alternative would be to consider non-statutory ways of increasing access to preventative breaks support for carers who may not yet want or need to be in contact with the wider social care system or to prepare a full adult carer support plan or young carer statement. Options for doing this might include expanding the existing non-statutory Short Breaks Fund.

Questions

Q9. For each of the below, please choose which factor you consider is more important in establishing a right to breaks from caring. (Please select one option from each line. Where you see both factors as equally important, please select 'no preference'.)

BSL Version of Question 9

Standardised support packages versus personalised support

• Personalised support to meet need
• Standardised levels of support
• No preference

A right for all carers versus thresholds for accessing support

• Universal right for all carers
• Right only for those who meet qualifying thresholds
• No preference

Transparency and certainty versus responsiveness and flexibility

• Certainty about entitlement
• Flexibility and responsiveness
• No preference

Preventative support versus acute need

• Provides preventative support
• Meeting acute need
• No preference

Q10. Of the three groups, which would be your preferred approach? (Please select one option.)

BSL Version of Question 10

• Group A – Standard entitlements
• Group B – Personalised entitlements
• Group C – Hybrid approaches

Please say why.

Using data to support care

Current issues and problems

At present, there is a wealth of data available about individuals in receipt of care and support, but it is not always easily available – including to service users and their carers – or used for maximum benefit.

Data about an individual is often held in multiple different places, making it difficult for people providing support across health and social care to access the most relevant, up-to-date information. This makes effective delivery of care, and continuity of care across different service providers and over time as care needs change, more challenging than it needs to be. It also hampers planning and development of services, research, and continuous improvement.

The pandemic has further emphasised that despite the volume of data, there remain significant information gaps and concerns around data quality and reliability. This includes, but is not limited to, information on care at home services, levels of unmet need, experiences of service users, and, crucially, the outcomes achieved for people. Most importantly, it makes it difficult to fully recognise and reflect a complete picture of an individual's personal needs and aspirations in an integrated approach that supports their wellbeing across health and social care.

In addition, there is a lack of a common approach to how data is recorded, what data is stored, and how service users are identified. This makes it challenging to provide services and understand things like equity of provision, and places additional burdens on individuals and provider organisations who may need to provide multiple different types of data to different commissioners for different purposes.

The gaps in existing data and intelligence are made worse by a vast array of formal and informal digital (and paper) systems for recording data across service providers. Data is overwhelmingly held in separate silos at the local level, so it is difficult to form a national picture. The increase in use of technology by individuals to manage their own care also generates a wealth of additional data (which is either captured in proprietary formats or probably held in silos).

This makes accessing and sharing of information to help improve and tailor the services being delivered to people far more challenging. And this extends to how information is shared from social care into and with health (and vice versa).

Early identification and prevention of issues as they arise is critical in delivering improved outcomes for people. For example, an individual who suffers from repeat falls at home will often only come into contact with the health service in relation to their fall when they injure themselves (e.g. break a hip), but repeated falls may suggest an underlying health issue. This data is often collected in social care systems if the person uses a telecare service, but not shared with GPs or the wider community healthcare team who cannot then proactively intervene to address possible causes and reduce the risk of further problems.

We know that social care users continue to be frustrated at having to repeat their care and support needs to different areas of the health and care system. In part, this frustration arises from the reasonable assumption that the sharing of care information is already happening. Information strategies have been developed and systems built to support the sharing of good quality data but we recognise there is a gap between expectation and reality when it comes to data sharing in the social care system.

The Independent Review of Adult Social Care (IRASC) Review set out an ambition for national provision for social care data and information. Whether a social care user, a health or care professional, or those involved in local and national decision making, health and social care provision needs to be enabled by consistent, effective, and efficient information. With the promise and opportunity of a National Care Service, we have the chance to meet this ambition and provide person-centred care and health information to help people plan and support their own care.

Relevant Independent Review of Adult Social Care Recommendations

The key IRASC recommendation relating to using data to support care is:

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

However, many of the recommendations (around 20) set out in IRASC are premised on the need for good quality data and digital infrastructure. Improved data and digital infrastructure are critical to helping people live fulfilling, independent lives; enabling professionals to support those people; facilitate ethical and collaborative commissioning; underpin regulation and improvement programmes; support workforce planning; and facilitate research and intelligence. Specific recommendations requiring improved data and digital infrastructure include but are not limited to:

• Recommendation 5: Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process
• Recommendation 10: Packages of care and support plans must be made more portable and supported people should not have to fight to retain support because they have moved home.
• Recommendation 12: A new National Care Service should prioritise improved information and advice for carers, and an improved complaints process. It should take a human rights based approach to the support of carers.
• Recommendation 17: The National Care Service should oversee local commissioning and procurement of social care and support by reformed Integration Joint Boards, with services procured from Local Authorities and third and independent sector providers.
• Recommendation 18: The National Care Service should lead on the aspects of social care improvement and support that are best managed once for Scotland, such as workforce development and improvement programmes to raise standards of care and support.
• Recommendation 38: A condition of funding for social care services and supports must be that commissioning and procurement decisions are driven by national minimum quality outcome standards for all publicly funded adult social care support.
• Recommendation 50: Careful analysis by a National Care Service, with its partners in the National Health Service, Integration Joint Boards and beyond, of opportunities to invest in preventative care rather than crisis responses, to avoid expenditure on poor outcomes such as those experienced by people who are delayed in hospital.

What we propose

A National Care Service (NCS) is an opportunity to meet expectations around how information is used to provide and support care, across all care settings and social care decision making at all levels.

Data for an integrated social care and health record

People expect their social care and health information, where appropriate and at the right time, to be available to the people that need to see it. We already have many means to record this information, so do not expect to replace medical records or other well-functioning systems where they already exist. However we do need a platform that can draw this, currently fragmented, information together to focus on people and their outcomes, rather than service provision.

The IRASC recommends a NCS address gaps in national provision for social care data.

Through the NCS, a nationally-consistent, integrated and accessible electronic social care and health record would be put in place that can be used and seen by all those who provide health and care support. Appropriate permissions and consent will be put in place to control who can see what information. This is not about imposing a single, new system but seeing the potential the NCS could provide to act as the additional national framework that allows for person-centred data and information to be shared safely and securely.

We would consider systems and functionality already in place as well as realising the opportunities that a NCS could provide to create new digital and data infrastructure. We would also learn from current specialised records, for example, the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which creates personalised recommendations for a person's clinical care and treatment in a future emergency in which they are unable to make or express choices.

Consistent, good quality and portable information would help people achieve their own goals and desired outcomes by ensuring those providing services have a better understanding of people's care and support needs. Your care plan would assist your care and support, be responsive to your changing needs and be accessible across different care settings. It will support the Getting it Right for Everyone national practice model, enabling all providers to ensure they are meeting your needs as set out in your care plan. It would allow you to control how different care services see and use your data, and give you confidence that the latest information is accessible across the care system and the healthcare system as appropriate.

In line with our strategic approach to digital health and care, this would be co-designed with users and their support networks. We will take particular care to respond to concerns over the security and governance of information. We need to ensure the appropriate and respectful use of personal data, with controls in place that maintain data confidentiality, to maintain people's trust. This includes support to those that may lack capacity to provide consent to share their data.

We would be transparent on the purpose of the information, transparent on who can access it, and transparent on how it can be shared. We would listen to the range of perspectives on these issues. It will be our responsibility to make sure everyone understands how their data is used. We will need to reassure those that are hesitant about data sharing and build-in an opt out option if required. Throughout, we will fully meet our privacy and security obligations.

Data to assist care and support across all settings

To provide the best possible care and support, and outcomes on a day-to-day basis, health and social care professionals need good quality, relevant, timely, and accessible data and intelligence that is consistently recorded in an agreed format using nationally-agreed definitions. In the context of a resident in a care home, for example, that means access to a care plan and care records by those outside of the care home providing support along with access for the care home to relevant data held by the NHS. A NCS would allow the safe and efficient sharing of data across all care settings and be clear on the agreed purposes to share data.

To achieve this we will look to introduce legislation to require all primary and community health care and social care services to provide data to the NCS. This would enable improved data for and from the vast array of health and social care providers (including both third sector and private providers). There would also be the opportunity to reduce the administrative burden of managing data and streamline data collection.

The NCS would make sure people's data and information moves with them from prevention and early intervention through to acute and specialist provision. Achieving this is an imperative, to make sure wherever care and support is accessed the right data is available to those that support and provide care.

Data to inform local and national decision making

Beyond the day-to-day care management, the NCS should be able to require data that can be used locally and nationally for strategic plans, commissioning, delivery monitoring, and performance reporting.

Aligning with the Digital First Service Standard, we will look to introduce legislation that requires data for local and national decision making to address the social care information gaps along with a requirement to meet common data standards and definitions.

We do not propose to set out the requirements themselves in primary legislation, as it cannot be changed fast enough to adapt to the rapid changes in technology and new ways of using data. We will set out a requirement that will be specified in guidance to meet common data standards and definitions for how that data is collected, received and stored.

A consistent approach to data and effective information infrastructure should also support service delivery, inform planning, facilitate better regulation (which in turn helps drive improving standards), and provide the data required for research and analysis. The NCS could be the driving force for true collaboration with a minimal viable social care dataset as a starting point to develop social care policy at the local and national level.

We also recognise that this would require additional investment in data and digital systems, locally as well as nationally. And investment in people to make sure they have the right skills to use and analyse these data. We need to help the workforce improve their understanding of how to provide and use quality data and why it matters, and we need to have data specialists to drive improvement and accountability.

Data Protection and Freedom of Information

Individuals have a legal right of access to information about themselves under Data Protection legislation, which will apply in addition to the systems that will be created to make sure people are able to use their own integrated social care and health record.

It is also important that people can get information more generally about health and care services. The National Care Service and Community Health and Social Care Boards will be subject to the requirements of the Freedom of Information (Scotland) Act 2002 (FOISA), as IJBs are at present. The Scottish Government consulted in 2019 on the future use of Scottish Ministers powers under section 5 of FOISA to extend Freedom of Information requirements to bodies that either exercise functions of a public nature or have a contract with a Scottish public authority to provide a service which is a function of that authority. This could potentially include private and third sector organisations that deliver health and social care functions. The analysis of that consultation was published in March 2020, and a paper setting out the Scottish Government's next steps will be published later in 2021. Any proposals will be subject to further detailed consultation as required by section 5 of FOISA.

Questions

Q11. To what extent do you agree or disagree with the following statements?

BSL Version of Question 11

There should be a nationally-consistent, integrated and accessible electronic social care and health record.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

Information about your health and care needs should be shared across the services that support you.

• Strongly Agree
• Agree
• Neither Agree/Disagree
• Disagree
• Strongly Disagree

Q12. Should legislation be used to require all care services and other relevant parties to provide data as specified by a National Care Service, and include the requirement to meet common data standards and definitions for that data collection?

BSL Version of Question 12

• Yes
• No

Please say why.

Q13. Are there alternative approaches that would address current gaps in social care data and information, and ensure a consistent approach for the flow of data and information across the National Care Service?

BSL Version of Question 13

Complaints and putting things right

How it works now

As part of the package of improving people's experience of social care services, it is important that, where things do not go well, people know how they can complain and there are effective systems to make sure things are put right. We also need to have good information about people's experience of care, to help understand where improvements could be made.

Currently, complaints can be made against individual registered services via the Care Inspectorate and for individual staff via the Scottish Social Services Council (SSSC). Feedback or complaints can also go via the local Health and Social Care Partnership (HSCP), this includes feedback/complaints on assessment, eligibility/payment and wait for care and support as well as about quality/safety of services.

If people are not happy with the decision relating to their complaint, from any of these bodies, they can approach the Public Sector Ombudsman for Scotland.

There is currently some limited information on experiences of social care and caring available from the Health and Care Experience Survey (HACE). HACE is carried out every two years by Health and Social Care Analysis. It provides insights into people's experiences of receiving care including how they felt about the decision making process, the support that they received, and their overall satisfaction. Although the current survey provides an insight into experience of care it does not have detailed information on the type of care received which limits our understanding of the context of the experience. Around 13,000 – 14,000 responses are received for care and support. The limited questions mean it is not possible to examine fully all the domains of quality and safe care.

Issues and problems

The current system could be viewed as complex with separate channels for feedback and complaints about those providing services and about individual staff. There is also no dedicated website or information for those who wish to give feedback or make a complaint as there is with the National Health Service.

The Competition and Market Authority report into care homes in 2017 recommended that for the market to work better for those using services there must be more support for those making decisions on care, but also critically that they must be protected when things do not work out.

Although detailed data is available on complaints via the Care Inspectorate and SSSC this could be viewed as difficult to find and may not be easily accessible for those who currently use services or those planning on using services.

HSCPs have different processes for handling complaints and feedback and one criticism of the current system is that it may not be uniform across areas.

Duty of candour legislation places a legal requirement on all health and care services (including independent and third sector organisations) that when things go wrong then people have a right to know what happened.

It is also recognised that people are not aware of advocacy services that are available to them or they are unable to access appropriate services. This can leave people without a voice and unable to articulate the issues they face.

A robust, credible system that people (or their advocates) can access easily to provide feedback and complaints is necessary for a well-functioning system. It is also critical that lessons are learned from feedback and complaints and a continuous response loop operates. Feedback and complaints should also be both monitored nationally to provide an overview of issues and used proactively by local bodies and the Care Inspectorate when reviewing the quality and safety of services. It is also critical to examine any previous feedback or complaints in light of adverse events.

It is also important that we are able to measure experience more broadly across social care than is currently the case. Experience is a key measure in any quality/safety framework and is directly related to outcomes. To date as the review states, "previous attempts to establish a single set of outcome measures across adult health and social care have been hampered by complexity and duplication. These obstacles need to be overcome to ensure clarity of purpose and transparency of the evidence base for progress".

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 8: More independent advocacy and brokerage services, including peer services, must be made available to people to ensure that their voices are heard, and to help prepare for participation in planning and organising their support.

Recommendation 9: When things do not work well for people and their rights have not been upheld, they must have rapid recourse to an effective complaints system and to redress.

Recommendation 12: A new National Care Service should prioritise improved information and advice for carers, and an improved complaints process. It should take a human rights based approach to the support of carers.

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

What we propose

We propose that there should be a national single point of access for information on making a complaint or giving feedback about social care, providing links where necessary to relevant organisations. This would also include information on what people can do if they are not content with the process, and an overview of advocacy rights and services. The same single point of access would provide relevant links to data/information on feedback and complaints.

Local systems for initial complaints and feedback should be strengthened so there are similar processes across local bodies who commission and deliver services. It is important that people feel that they can still approach local community health and social care bodies and that where possible feedback or complaints are dealt with at that level.

We will consider developing a charter for rights and responsibilities, as there are for health, for carers, and for Social Security Scotland. A charter would provide clarity as to what rights and responsible individuals, their families, and their carers can expect and outline clearly the process for feedback and complaints.

Local bodies will be required to demonstrate that they have informed clients, their families, and carers about advocacy services and their right to a voice.

We will consider whether it is appropriate to appoint a commissioner for social care. A commissioner would champion the rights of those who receive care and support, their families, and carers and ensure they are protected by the law. The commissioner and the office would act on behalf of those who receive care and support. We would need to consider carefully the role of such a commissioner, as it could overlap with the responsibilities of other existing commissioners, such as the Children and Young People's Commissioner, and others which have been proposed including the Patient Safety Commissioner.

Feedback and complaints should be used proactively with other data and intelligence to understand the quality and safety of services nationally and locally. Relevant national information should be fed back to local bodies who commission and work with services on a day to day basis. Specifically, any trends in feedback or complaints relevant to certain parts of the sector or across one provider should be proactively addressed.

Care providers will be required to demonstrate they have taken feedback and complaints on board when they are inspected. This will be used as a key outcome measure. Experience of care has been found to be a powerful indicator of people's outcomes. An outcome is the result or the effect of care and support, it will be directly impacted by the care or support received but also by the process around that care and support such as communication and timeliness of care and support.

We will carry out a review of capturing experience in adult social care. This may include a survey but also potentially other methods. A key theme to capture will be how people feel about communication as this is consistently raised in complaints. Other themes may include timeliness of care and support, how supported individuals were in decision making, and safety.

Questions

Q14. What elements would be most important in a new system for complaints about social care services? (Please select 3 options)

BSL Version of Question 14

• Charter of rights and responsibilities, so people know what they can expect
• Single point of access for feedback and complaints about all parts of the system
• Clear information about advocacy services and the right to a voice
• Consistent model for handling complaints for all bodies
• Addressing complaints initially with the body the complaint is about
• Clear information about next steps if a complainant is not happy with the initial response
• Other – please explain

Q15. Should a model of complaints handling be underpinned by a commissioner for community health and care?

BSL Version of Question 15

• Yes
• No

Please say why.

Q16. Should a National Care Service use a measure of experience of those receiving care and support, their families and carers as a key outcome measure?

BSL Version of Question 16

• Yes
• No

Please say why.

Residential Care Charges

How it works now

Current regulations and guidance provide the framework for local authorities to charge for the residential care that they provide or arrange. The local authority will carry out a financial assessment on any individual requiring or choosing to have residential care to determine how much someone is expected to contribute towards their care home costs.

The financial assessment looks at a person's resources compared to a number of set levels called 'capital limits'. Currently, anyone with capital (including property) of more than £28,750, must meet their care costs (over and above any assessed entitlement to free personal and nursing care) in full. These individuals are commonly referred to as 'self-funders'.

Where capital falls between £18,000 and £28,750 a resident will be expected to contribute a proportion of their assets towards the cost of care. If someone has capital of £18,000 or less, they will not ordinarily be asked to contribute towards the cost of their care and be placed within a care home on the National Care Home Contract (NCHC). The NCHC is negotiated annually between local authorities and care providers and provides a framework for national charging for residential care.

The Scottish Government are aware of instances where families are asked to contribute to care over and above the NCHC rate by care home operators.

These capital limits are ordinarily uprated each year in line with inflation

By comparison, England and Northern Ireland have a lower capital limit of £14,250 and an upper capital limit of £23,250. In Wales there is a single capital limit of £50,000.

Residents are expected to contribute to care home fees from income such as their pensions, but are entitled to keep an amount for personal expenses (the Personal Expenses Allowance). This is currently set at £29.30 per week.

Adults who have been assessed as requiring Personal Care do not pay for this service, regardless of their condition or means. Nursing Care is also free at the point of delivery. The local authority pay for these elements of the residential care for all those assessed as needing them. The current rates are £193.50 per week for Personal Care and £87.10 per week for Nursing Care. For self-funders, this payment is made directly to the provider on behalf of the resident.

These rates for Personal and Nursing Care are generally uprated each year by inflation. However, the cost of providing these services has increased above inflation in recent years, meaning the rates of payment have not kept pace. To help address this, for 2020/21 we increased the rates by 7.5%. However, some stakeholders expressed concern that care providers would increase their fees by an equivalent amount and self-funders will not see any benefit.

Issues and problems

The Independent Review of Adult Social Care (IRASC) makes an associated recommendation to remove charging for non-residential social care. If this were to be implemented it should mean that the only cost for people in receipt of social care should be the means tested accommodation costs for care home residents.

However, in recent years the cost of providing Free Personal and Nursing Care has increased significantly and the payment made to providers by local authorities for self-funding residents has not kept pace with this. This is not an issue for local authority funded placements covered by the NCHC, which IRASC felt contains reasonable provision for the cost of Free Personal and Nursing Care.

IRASC estimated that the cost of increasing these payments on behalf of self-funders to the rate paid by local authority-funded placements to be in the region of £116 million per year.

IRASC did not consider in detail whether adjustments should be made to the means testing arrangements of the residential charging regime, though it suggested that this may be something the NCS may wish to consider in future.

Over a number of years the current level of capital limits have been criticised as they capture many middle and lower income households.

Relevant Independent Review of Adult Social Care Recommendation

Recommendation 51. Additional investment in order to increase the sums paid for Free Personal and Nursing Care for self-funders using care homes to the levels included in the NCHC.

What we propose

In line with the IRASC recommendation, increase the sums paid for Free Personal and Nursing Care for self-funded care home residents to the levels included in the NCHC or consider alternatives, such as revising means testing, to assist in ensuring self-funding residents are treated fairly in their financial assessment.

Questions

Q17. Most people have to pay for the costs of where they live such as mortgage payments or rent, property maintenance, food and utility bills. To ensure fairness between those who live in residential care and those who do not, should self-funding care home residents have to contribute towards accommodation-based costs such as (please tick all that apply):

BSL Version of Question 17

• Rent
• Maintenance
• Furnishings
• Utilities
• Food costs
• Food preparation
• Equipment
• Leisure and entertainment
• Transport
• Laundry
• Cleaning
• Other – what would that be

Q18. Free personal and nursing care payment for self-funders are paid directly to the care provider on their behalf. What would be the impact of increasing personal and nursing care payments to National Care Home Contract rates on:

BSL Version of Question 18

• Self-funders
• Care home operators
• Local authorities
• Other

Q19. Should we consider revising the current means testing arrangements?

BSL Version of Question 19

• Yes
• No

If yes, what potential alternatives or changes should be considered?