A National Care Service for Scotland: consultation

Scope of the National Care Service

BSL version of Chapter 3: Scope of the National Care Service

Children's services

How it works now

The provision of children's social work and social care services is inextricably related to the provision of services to adults. By children's services we mean any service provided to or for the benefit of children by either a local authority, Health Board, Third Sector, or commissioned provider, including those who are leaving or have left care, children with complex health conditions, young people involved in offending behaviour, or those with additional support needs.

A number of Integration Joint Boards (IJBs) already have children's services delegated to them with the remainder remaining within local authorities. For example of the 31 IJBs:

• 19 currently have Children's Health delegated,
• 10 have Children and Families Social Work
• 15 are responsible for Justice Social Work

Where children's services are not delegated to an IJB they have remained within the local authority, often within the Education Department.

Alongside this is a complex statutory framework for social work and care, contained in a number of pieces of legislation cutting across both adult and children's services, in addition to children-specific legislation.

The complexity is such that there are significant implications for children's social work and care services – given it can be particularly difficult to separate out social care support for adults with the social care needs of the children who live with them.

Issues and problems

Not including children's social work and social care within the National Care Service (NCS) risks fragmenting the current system of care and assessment and further adding to complexity for services users – a key issue highlighted by Independent Review of Adult Social Care (IRASC). Any changes to the adult social care system must also take account of the need for parents of children within or at risk of being involved in the care system being able to access treatment early to keep children in loving homes. Whilst for disabled children, continuity of care and support as they transition to adulthood is essential.

Separating the delivery arm of the process by creating a National Care Service focused solely on adult social care would also have consequences for the ambition that improved planning and commissioning functions will deliver through having both social work and social care within the NCS, whilst ensuring continuity of risk management and the protection of human rights.

Whilst the IRASC specifically focused on adult social care, it should be seen in the context of the Promise, the United Nation's Convention on the Rights of the Child (UNCRC), Getting It Right for Every Child (GIRFEC), and other children's policy areas such as increasing the Age of Criminal Responsibility.

The Promise concluded that "for Scotland to truly to be the best place in the world for children to grow up, a fundamental shift is required in how decisions are made about children and families". For this fundamental shift to happen services have to be designed in a truly collaborative way – IRASC therefore provides an opportunity to look holistically at the system of support for children, young people and their families.

Relevant Independent Review of Adult Social Care Recommendations

The IRASC was clear that its focus was on adult social care - it therefore did not consider issues relating to children and family services (by which we mean the provision of social work and social care services to children and families).

It did note though that "Social workers were also concerned about the impact possible fragmentation would have on children, families and adults needing support and who do not lead their lives according to administrative boundaries or arrangements. Careful consideration should be given to these concerns as changes are taken forward and close joint working forged between the implementation of The Promise and the recommendations in this report".

What we propose

Our proposal therefore is that children's social work and social care services should be located within the NCS to ensure a more cohesive integration of health, social work, and social care. By doing so, it affords the opportunity to address the unanticipated consequence of integration where children's social work is currently fragmented across different public bodies in different integration arrangements.

Having children's social work and social care within the NCS will provide the opportunity for services to become more cohesive – built around the child, family, or person who needs support – reducing complexity and ensuring improved transitions and support for those that need to access a range of services, including improved links with health. Location within the NCS would also permit us to have a system where access, assessment, funding, and accountability is in one body. In doing so we need to retain and strengthen the existing links with Education and Early Learning and Childcare.

The overarching purpose will be to ensure consistent delivery of services to the most vulnerable children and families, which is inextricably related to the provision of services to adults. In doing so we need to ensure that access to services and reduced complexity for service users is a fundamental principle – this being one of the key messages from the IRASC.

Questions

Q23. Should the National Care Service include both adults and children's social work and social care services?

BSL Version of Question 23

• Yes
• No

Please say why.

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

BSL Version of Question 24

For children with disabilities,

• Yes
• No

Please say why.

For transitions to adulthood

• Yes
• No

Please say why.

For children with family members needing support

• Yes
• No

Please say why.

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

BSL Version of Question 25

• Yes
• No

Please say why.

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

BSL Version of Question 26

• Yes
• No

If yes, please give examples

Healthcare

How it works now

Primary care is generally people's first point of contact with the NHS. This includes contact with community based services provided by general practitioners (GPs) and others including dentists, optometrists, pharmacists and physiotherapists.

Community based healthcare services in Scotland provided by the NHS and third and independent sectors play a key role in our health and care system and cover a wide range of services provided by registered nurses, midwives, and allied health professionals. This includes, for example, community nurses (district nursing, general practice nurses, prison health nurses, care home nurses, community mental health and learning disability nurses, clinical nurse specialists, health visitors, family nurses, school nurses, and community children's nurses) and allied health professionals such as physiotherapists, occupational therapists, podiatrists, dieticians, and speech and language therapists.

These services play a key role in keeping people well, providing holistic, rights-based, and person-centred care. This includes assessing and anticipating care needs, supporting self-management, treating and managing acute illness, long-term conditions, supporting palliative and end of life care at home or in a community setting, and supporting people to live independently in their own homes.

Community health care teams work closely with Primary Care General Practice teams and alongside social work and social care teams to meet people's health and social care needs. The level of joined up working across community health and social care can vary across Scotland, often as a result of silo working or complex referral systems which impact on seamless care and continuity.

The Primary Medical Services (Scotland) Act 2004 amended the National Health Service (Scotland) Act 1978 by placing a duty on Health Boards to provide or secure "primary medical services" for their populations. Health Boards can contract with general practitioners to deliver services and/or run their own. The majority of GP practices in Scotland are run by GPs as independent contractors. They contract with the Health Board to deliver medical services and in turn they receive funding to provide those services based on the size of their patient list and other factors. The remaining practices are run by the Health Boards directly. The GP contract is nationally negotiated.

Other services such as dentistry, pharmacy, and optometry may also be provided by independent contractors in a similar way.

The Public Bodies (Joint Working) (Scotland) Act 2014 was introduced to ensure that health and social care services are well integrated, so that people receive the care they need at the right time and in the right setting, with a focus on shifting the balance of care from hospital to community settings with a focus on prevention, anticipatory care, and early intervention.

The Act requires local authorities and Health Boards to delegate powers and funding to an integration authority, usually an Integration Joint Board (IJB). The integration authority is then responsible for planning what care is needed in its area and for directing (and providing funding to) the Health Board and the local authority to deliver it.

Integration authorities are responsible for planning and commissioning almost all primary care and community-based health care. They also carry out strategic planning for Accident and Emergency services and inpatient hospital services for certain types of medicine. This is intended to help integrate services to avoid the need for hospital care where it is preventable, for example where better social care could help a person to manage their health condition at home.

All healthcare commissioned by the Integration authorities is provided or contracted by the Health Board. NHS provided community based services fall under NHS legislation and are free at the point of access. Unlike social care there is no eligibility criteria for accessing community health care.

The fact that all healthcare continues to be provided through the Health Board, although commissioned by the integration authority, allows the Health Board to maintain responsibility for clinical and professional governance arrangements for services provided and professionals employed by the NHS. This is the process by which accountability for the quality of health care is monitored and assured, supporting staff in continuously improving the quality and safety of care.

Issues and problems

The Independent Review of Adult Social Care (IRASC) identified that integration of health and social care has not worked as well as it should have done, particularly due to a lack of collaborative leadership in some areas. Where there is tension between Health Boards, local authorities, and IJBs it can stifle progress and innovation. It can also lead to community health services not aligning adequately with social care and hospital-based health care to provide a whole system approach to health and social care.

As the GP contract is a nationally negotiated contract there are limits to the ability of the IJB to influence GP service delivery.

There can be challenges of communication and cultural differences between workers in different areas of health care, social work and social care. These can cause difficulties in providing integrated, person-centred care for an individual and on the approaches to governance and quality improvement. Effective professional and clinical and care governance structures are critical to supporting professionals to work together better across these traditional boundaries.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 17: Integration Joint Boards should manage GPs' contractual arrangements, whether independent contractors or directly employed, to ensure integration of community care and support provision, to respect and support professional interdependencies, and to remove the current confusion about where responsibility for primary care sits.

The IRASC suggests that a National Care Service should ensure effective working with NHS Scotland, establishing a joint approach where beneficial to people accessing care. This priority could be enabled by the creation of a similar board of governance for NHS Scotland and the creation of a National Integration Joint Board where the senior leadership of the National Care Service and NHS meet regularly to agree strategy and priorities.

It also proposes that The National Care Service should develop and maintain the distribution formula for direct allocation of budgets by the Scottish Government to Integration Joint Boards and national care bodies.

What we propose

IRASC was only concerned with adult social care, and therefore did not make further recommendations in relation to health. However, the ambition for the National Care Service is to go further and deliver consistent, person-centred, community health and social care services for all ages. It would also be possible to consider the National Care Service, and in turn, Community Health and Social Care Boards, taking responsibility for the commissioning and procurement of a range of health services, similar to (and potentially wider than) the range of services currently delegated to Integration Joint Boards. This commissioning is already done to an extent by IJBs. We are seeking your views on what services might be included in this responsibility.

In line with the recommendations of IRASC, we also propose that Community Health and Social Care Boards (CHSCBs) should manage GPs' contractual arrangements.

In doing so, and in any consideration of distribution formula for direct allocation of budgets by the National Care Service, it should take into account the recommendations of the Remote and Rural General Practice Working Group, in their report "Shaping the Future Together", including the recommendation to "review the method of funding allocations to territorial Boards with significant remote and rural areas, including Island Boards, in the light of changing demographics, care needs and evolving models of care provision".

We recognise that any such reforms will need to make appropriate arrangements for clinical and professional governance, and to consider the opportunities available for staff. How any reforms align with the role of Healthcare Improvement Scotland will also need careful consideration. We do not envisage a wholesale change in employment status for people in the NHS, rather that robust commissioning and procurement arrangements are in place. Regardless of which organisation plans, commissions and delivers services, health and social care professionals will require to continue to work in an integrated way to support the person-centred approach to care that we seek to deliver.

Questions

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

BSL Version of Question 27

• Yes
• No

Please say why.

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

BSL Version of Question 28

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

BSL Version of Question 29

• Better integration of health and social care
• Better outcomes for people using health and care services
• Clearer leadership and accountability arrangements
• Improved multidisciplinary team working
• Improved professional and clinical care governance arrangements
• Other (please explain below)

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

BSL Version of Question 30

• Fragmentation of health services
• Poorer outcomes for people using health and care services
• Unclear leadership and accountability arrangements
• Poorer professional and clinical care governance arrangements
• Other (please explain below)

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

BSL Version of Question 31

Social Work and Social Care

How it works now

Social work is a profession with responsibility for discharging statutory powers and duties and is deep rooted in human rights across all age ranges and care groups – it is also key to the assessment of need and the planning, commissioning, and delivery of social work and social care services.

Social work has a key role in the co-ordination and delivery of social care support for adults, children, and often whole families, supporting individuals and families to manage the transition from children and family services into adult care services. Social workers provide direct support, help, and signposting to people in assessing their need for social care. The assessed need is then delivered through social care services. Subsequently, social workers have a responsibility for monitoring and reviewing care to ensure the individual's needs continue to be met. They also ensure safeguarding through their statutory responsibilities including Adult Support and Protection, Child Protection, Mental Health Care and Treatment, Adults with Incapacity, and Public Protection.

Social work has a complex statutory framework cutting across adults' and children's services and criminal justice services. The Public Bodies (Joint Working) (Scotland) Act (2014) resulted in social work across these areas being delivered across a variety of structures within Integrated Joint Boards and Councils

Issues and problems

Careful consideration is needed about how to best use the professional qualified skills of social workers, recognising their direct relationship with social care across all age groups.

Not including all social work and children's social care within the National Care Service (NCS) risks fragmenting the current system of care and assessment and further adding to complexity for services users – a key issue highlighted by Independent Review of Adult Social Care (IRASC). It can be particularly difficult to separate out social work support for adults with the social work and social care needs of the child who live with them.

Creating a NCS to deliver only adult social care, whilst retaining social work duties and responsibilities within local authorities would have consequences for the NCS's ambition to improve planning and commissioning functions, and for ensuring continuity of risk management and the protection of human rights.

Relevant Independent Review of Adult Social Care Recommendations

Whilst IRASC focused on adult social care, its findings have led to further consideration about how adult, children and justice social work and social care are intrinsically linked, how we improve social work and health and social care outcomes for individuals and their families and how changes will empower people to engage with their care either in the short or longer term, depending on their needs.

IRASC noted that, "Social workers were also concerned about the impact possible fragmentation would have on children, families and adults needing support and who do not lead their lives according to administrative boundaries or arrangements. Careful consideration should be given to these concerns as changes are taken forward and close joint working forged between the implementation of The Promise and the recommendations in this report".

What we propose

Our proposal therefore is that duties and responsibilities for social work and adult and children and families' social care services should be located within the NCS to ensure a more equitable and cohesive integration of health, social work and social care. By doing so, it affords the opportunity to address the unanticipated consequence of integration where social work and social care is currently fragmented across different public bodies in different integration arrangements.

It will provide the opportunity for services to become more cohesive – built around the child, family, or person who needs support – reducing complexity and ensuring improved transitions and support for those that need to access a range of services. Location within the NCS would also permit us to have a system where access, assessment, funding and accountability is in one body.

Including social work within the NCS would mean social work's legal powers and expertise would remain inextricably linked with the delivery of care, and with the work of a National Social Work Agency (see page 88) to enable the consistent scaling up of good practice.

Questions

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

BSL Version of Question 32

• Better outcomes for service users and their families
• More consistent delivery of services
• Stronger leadership
• More effective use of resources to carry out statutory duties
• More effective use of resources to carry out therapeutic interventions and preventative services
• Access to learning and development and career progression
• Other benefits or opportunities, please explain below

Q32. Do you see any risks in having social work planning, assessment, commissioning and accountability located within the National Care Service?

BSL Version of Question 33

Nursing

How it works now

In Scotland registered nurses are the largest group of clinicians within the NHS responsible for the delivery of safe, person centred, and effective care and treatment. Social care services, mainly the independent care home sector, also employ registered nurses. Registered nurses within health and social care services play a pivotal role in prevention, anticipatory care planning, early intervention, assessment, treatment, recognition of deterioration, and palliative and end of life care. They play a key role as part of the wider integrated multi-disciplinary team working within the Health and Social Care Partnership (HSCP) as well as supporting the wider social care team.

Professional and clinical governance - for nursing, midwives, allied health professionals such as podiatrists, physiotherapists, speech and language therapists, dietitians, and clinical health care support workers working within the HSCP - is retained within the structures of the local Health Board which delegates the service to the integration authority. These groups are professionally accountable to the NHS Board Executive Director of Nursing.

NHS Board Executive Directors of Nursing, Midwifery and Allied Health Professionals (AHPs) are appointed by the Scottish Ministers and are responsible for professional and clinical care governance and providing the Health Board with assurance on the standards of care to ensure services are safe, person centred and effective. They do this through a delegated framework to other professional clinical leaders within the organisation.

Other clinical staff may be employed by services delegated or commissioned by the integration authority, such as independent care homes or GP contracted services. Under current legislation the NHS Board Executive Director of Nursing, Midwifery and AHPs does not have professional accountability or responsibility for these services. Professional and clinical governance for this group of staff is provided through their employer.

There is limited data on the nursing workforce within social care but' we know that there is a vast variation in the provision of and access to nursing support throughout Scotland. Whilst some independent services do employ specialist nurses, not all do. We estimate only around half of adult and older peoples care homes in Scotland have registered nurses. For care homes that do not employ registered nurses, nursing care is provided by NHS community nursing services, which may include district nursing, care home liaison nurses, community mental health and learning disability nurses, and Advanced Practice Models may be used.

All statutory regulated health care professionals such as registered nurses, allied health professionals, and doctors must comply with their regulatory bodies' standards of conduct and practice. Registered Nurses at all levels including Executive Directors of Nursing are regulated by the Nursing and Midwifery Council and must comply with the Nursing and Midwifery Code and revalidation requirements.

Issues and problems

Throughout the COVID-19 pandemic, measures have been taken to provide additional oversight and support to the social care sector and to the care home sector in particular. The challenge of providing safe environments for often our most vulnerable of citizens during the COVID-19 pandemic is significant. The Cabinet Secretary for Health and Sport wrote to Health Boards on 17th May 2020 setting out new local oversight arrangements including Executive Directors of Nursing Midwifery and AHPs to provide support to the social care sector through their delegated nursing leadership frameworks within the HSCPs and acute hospitals. This largely focused on infection prevention and control and care assurance in care homes. NHS Board Executive Directors of Nursing, Midwifery and AHPs provided additional support from infection prevention and control nurses and community and speciality nursing teams, who have provided infection prevention and control advice, support and expertise and oversight throughout the COVID-19 pandemic..

On 23 March 2021 the then Cabinet Secretary for Health and Sport asked that enhanced multidisciplinary arrangements to support care homes and the wider social care sector, including care at home settings, be kept in place until at least March 2022. It was noted that through the direct involvement of Executive Directors of Nursing, significant improvements have been made in the standards of care and infection prevention and control within our care homes. Also, the efforts of Executive Directors of Nursing and their delegated nursing leads working with multidisciplinary teams and the care home sector have driven reductions in both outbreaks and deaths from COVID-19 in the sector.

The value of multi-disciplinary working has been key to the response to the pandemic. Understanding the roles, responsibilities, knowledge, expertise, and the unique contribution of each professional within a person's care is essential to ensuring good outcomes for people. We know that people who live in adult and older people's care homes have increasing levels of health and support needs, and are likely to have increasing levels of complexity and co-morbidity, living with frailty, dementia, disability, and neurological illness. Care homes are also one of the largest providers for palliative and end of life care. The role of the wider multidisciplinary team, in particular registered nurses, are key to ensuring peoples full health and care needs are met.

Registered nurses also provide leadership and expertise to the wider social care team in supporting them with education and training, attainment of competencies, care planning, recognition of deterioration and supporting palliative and end of life care. Whilst it is acknowledged that care homes are not clinical settings and nor should we wish them to be, it is important to recognise that many people who receive social care have health and social care needs and to enable them to live their best life it is important that all their needs are met. To achieve this it is important that we have collective and seamless working across all professional groups within health and social care. Shared learning across health and social care teams is critical to ensuring that people across Scotland receive the best care possible.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 21: The National Care Service in close co-operation with the NHS should establish joint 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.

Recommendation 27: The safety and quality of care provided in care homes must be improved to guarantee consistent, appropriate standards of care.

What we propose

It is important that we have professional nursing governance and assurance across community health and social care services. This should be of a similar standard to that provided for registered nurses and healthcare support workers working in hospitals and would build on the role that Executive Directors of Nursing, Midwifery and AHPs and their professional leadership teams have taken during the COVID-19 pandemic in care homes.

We propose to maintain the current Executive Director role to provide professional leadership across community health and social care. Executive Directors of Nursing will continue to :

• provide professional leadership to support the health and care needs of care home residents supporting prevention, anticipation, early intervention, recognition of deterioration, and palliative and end of life care.
• use information from the safety huddle tool and other mechanisms through the oversight arrangements to identify where specific nursing support may be required
• facilitate assurance/professional support for quality outcomes and safety through the provision of professional and clinical advice on standards of practice, education requirements and quality of care.
• ensure provision of specific infection protection and control expertise and support including reviewing and recommending actions to be taken in relation to infection protection and control practice, cleaning regimes, and appropriate and effective use of personal protective equipment to prevent transmission of infection
• continue to support the identification of education and training needs of staff in care homes, supporting them to enhance their skill and knowledge in infection protection and control and other clinical aspects of care and maintain standards of care.

The advisory role provided by Executive Directors for Nursing, Midwifery and AHPs and their teams are currently focussed on adult care homes. However to, ensure parity of care and support and early intervention this could, be extended to include other social care environments such as care at home services, where it could improve outcomes for people in their own homes who have health and social care needs.

The role could also be extended from the current advisory and oversight role to a role of accountability, with the National Care Service overseeing and ensuring consistency of access to education and professional development of social care nursing staff, standards of care, and governance of nursing providing within social care service. The National Care Service could also be responsible for the commissioning of nursing in social care.

Questions

Q34. Should Executive Directors of Nursing have a leadership role for assuring that the safety and quality of care provided in social care is consistent and to the appropriate standard? Please select one.

BSL Version of Question 34

• Yes
• No
• Yes, but only in care homes
• Yes, in adult care homes and care at home

Please say why

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

BSL Version of Question 35

• Yes
• No, it should be the responsibility of the NHS
• No, it should be the responsibility of the care provider

Please say why

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

BSL Version of Question 36

• Yes
• No

If no, please suggest alternatives

Justice Social Work

How it works now

Community justice has a vital role in preventing offending and delivering effective interventions which keep communities safe and tackle offending behaviour. At the core of community justice is effective delivery of community sentences, other community-based interventions (such as supervision of those on bail) imposed by the courts, and the supervision of relevant individuals upon release from custody. Justice social work (JSW) services, as part of local authorities, take a lead role in the delivery of community interventions, with support from partners including third sector organisations.

A large number of people who come into contact with the justice system have a wide range of often complex needs. Holistic approaches are required which take account of an individual's health - including mental health, trauma, and drug and alcohol related issues - housing, employability, and risk of harm to self and others. Collaboration with victims organisations and communities is also needed to help increase public understanding of and confidence in community interventions. The Scottish Government has a long-stated ambition to take an approach to criminal justice that focuses on prevention, treatment, and rehabilitation, rather than a model solely focused on punishment and containment.

The current model for community justice came into operation on 1 April 2017, underpinned by the Community Justice (Scotland) Act 2016 (the 2016 Act), which places duties on a group of statutory partners to engage in community justice planning and to report against a set of nationally-determined outcomes. This relies on effective partnership working at both local and national levels. Community justice partnerships in local authority areas are made up of a number of statutory partners and are supported by Community Justice Scotland, which was established by the 2016 Act. Although some community justice partnerships are aligned to governance arrangements associated with Integration Joint Boards (IJBs), others are not. The proposed creation of a National Care Service (NCS) with directly funded Community Health and Social Care Boards (CHSCBs) to deliver services locally may provide an opportunity to improve accountability create more consistency, and improve outcomes for people working with community justice services.

A focus on prevention and effective community interventions has helped see Scotland's reconviction rate fall to its lowest level since comparable records began. The average number of reconvictions per offender has decreased by 23% over the past decade from 0.60 in 2008-09, to 0.46 in 2017-18. This approach is based on strong evidence that community interventions are more effective than short custodial sentences. The presumption against short sentences was extended to apply to custodial sentences of 12 months or less in 2019, to help enable a further shift to community sentencing and help prevent reoffending.

However, Scotland still has one of the highest prison populations per capita in Western Europe and a range of measures are being taken to increase availability of and confidence in community interventions. We will continue to take forward commitments made by the Scottish Government in relation to community justice, whatever the outcome of this consultation.

In particular, the Scottish Government will review the National Strategy for Community Justice this year, and will consider how to build on progress over recent years to further encourage the use of community interventions where appropriate, including through a substantial expansion in the availability of diversion from prosecution and of community justice services.

The Scottish Government has also committed to exploring legislative options for a sustainable reduction in the prison population, with a focus on managing offending behaviour – and reducing re-offending – in the most effective way.

Social work services play a critical role in the delivery of adult social care and as such, if social work in general were to become part of the NCS, there could be value in considering the integration of JSW services as well, to ensure a consistent approach. This may also help address some identified issues around consistency and equity of access in relation to JSW services, and to enable a shift towards a public health based approach to preventing offending, community based interventions, and rehabilitation.

Issues and problems

There are a number of issues affecting community justice and JSW services which are relevant to consideration of future options.

Ensuring consistency of access to services across Scotland is a challenge, and has been a longstanding concern. With better coordination, a set of minimum standards, and the appropriate resources, the delivery of effective and person-centred community justice services could be made much more consistent across the country and improve outcomes for individuals, families, and communities. There are a number of ways to achieve this and one may be through inclusion of aspects of community justice in the NCS.

It is noted that the proposed changes will not preclude work on the strategic approach to community justice being taken forward, or work with Community Justice Scotland, Social Work Scotland, and others linked to the Recover, Renew, and Transform programme which is focused on the impact of coronavirus on the justice system.

Relevant Independent Review of Adult Social Care Recommendations

The Independent Review of Adult Social Care (IRASC) found compelling evidence of where current integrated arrangements were working well under IJBs and their delivery arm, Health and Social Care Partnerships (HSCPs). This was especially the case where all social care, social work and community based healthcare were delegated to its greatest extent. The review noted that there is scope to be more consistent in these arrangements and embed the effective working they saw throughout the country.

IRASC was clear that its focus was on adult social care - it therefore did not consider issues relating to JSW services.

However it did note that: "Social workers were also concerned about the impact possible fragmentation would have on children, families and adults needing support and who do not lead their lives according to administrative boundaries or arrangements. Careful consideration should be given to these concerns as changes are taken forward".

As such, the establishment of a NCS could have a significant impact on JSW services, the delivery of community interventions, and accountability within community justice.

IRASC also recommended establishing a national organisation for training, development, recruitment and retention for adult social care support, including a specific Social Work Agency for oversight of professional development (Recommendation 45). IRASC highlighted that training and professional development needs to be appropriately resourced.

What we propose

Including JSW services as part of the NCS could have some benefits, including addressing longstanding concerns about the consistency and availability of community justice services, and creating greater links to related public health services. The future model for the delivery of community justice services continues to be a live issue, particularly in the context of wider priorities around reducing the prison population and encouraging a further shift towards community interventions, and moving to a more national approach could aid these developments. In addition, if a NCS is established which includes some or all social work services with the exception of JSW, there is a risk that service provision could become more disjointed, and that JSW would not benefit from other reforms to the social work profession.

However, if JSW were to be included with the NCS, this would (as with other elements of social work and social care) involve transferring the relevant statutory responsibilities and revising highly complex funding and delivery arrangements, while ensuring that effective partnership working and service provision is not disrupted. This would require significant time and resources. If JSW services are to be included in the NCS, therefore, we suggest they might be transferred in a later phase of the process. However, we are inviting views now on whether they should, ultimately, be included.

Views from partners on the opportunities, risks, and potential benefits and challenges of any proposed changes that the NCS may bring to the model of community justice, and the relationship of community justice partnerships to CHSCBs, are crucial. Ultimately, the aim is to ensure the availability of community justice services that can command confidence, and better respond to the needs, and circumstances of individuals involved in the justice system, their families, and communities.

Questions

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

BSL Version of Question 37

• Yes
• No

Please say why.

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

BSL Version of Question 38

• At the same time
• At a later stage

Please say why.

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

BSL Version of Question 39

• More consistent delivery of justice social work services
• Stronger leadership of justice social work
• Better outcomes for service users
• More efficient use of resources
• Other opportunities or benefits - please explain

Q40. What risks or challenges do you think could come from justice social work being part of the National Care Service? (Tick all that apply)

BSL Version of Question 40

• Poorer delivery of justice social work services
• Weaker leadership of justice social work
• Worse outcomes for service users
• Less efficient use of resources
• Other risks or challenges - please explain

Q41. Do you think any of the following alternative reforms should be explored to improve the delivery of community justice services in Scotland? (Tick all that apply)

BSL Version of Question 41

• Maintaining the current structure (with local authorities having responsibility for delivery of community justice services) but improving the availability and consistency of services across Scotland
• Establishing a national justice social work service/agency with responsibility for delivery of community justice services
• Adopting a hybrid model comprising a national justice social work service with regional/local offices having some delegated responsibility for delivery
• Retaining local authority responsibility for the delivery of community justice services, but establishing a body under local authority control to ensure consistency of approach and availability across Scotland
• Establishing a national body that focuses on prevention of offending (including through exploring the adoption of a public health approach)
• No reforms at all
• Another reform – please explain

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

BSL Version of Question 42

• Yes
• No

Please say why.

Prisons

How it works now

Responsibility for healthcare in prisons was transferred to the NHS in 2011 and is delegated to integration authorities as a result of the Public Bodies (Joint Working) (Scotland) Act 2014. However, social care in prisons is not integrated and continues to be delivered by the Scottish Prison Service.

Over the past two years the Health and Social Care Integration in Prisons Workstream of the Scottish Government's Health and Social Care in Prisons Programme has collaborated with key stakeholders to carry out a pilot in six prisons to look at ways to achieve better integrated health, social work, and social care services and support for people in prison. Work was also commissioned with the aim of better understanding the social care support needs of Scotland's prison population. A report on the workstream findings is due to be published later in 2021

Issues and problems

The workstream recognised the positive work already happening in prisons that supports people in custody and those being liberated. However, it also identified opportunities to improve and strengthen the multi-disciplinary approaches in key areas, including integrated services.

People in prison with physical health needs already receive personal care arranged directly by the Scottish Prison Service. However, those with needs that may be less visible, such as learning disability, mental health difficulties, and substance use are not getting access to integrated services that encompass health, social work, and social care which would include the opportunity for a holistic assessment of needs.

The issue of how to make best use of social work resources was present throughout the project. Whilst both social workers based in prisons and community-based social workers have distinct functions, opportunities were identified for a more cohesive approach to social work delivery. This could maximise opportunities for individuals to access treatment, care, and rehabilitation to support them to lead positive lives within prison and then to move on and seek employment, support their families, and contribute positively to their communities on liberation. With greater support on their return to the community the likelihood of crisis, and thereby return into the justice system, could be reduced.

Barriers to achieving integrated services were identified in the report with challenges relating to data sharing being one of particular complexity. There is a lack of joined up systems enabling data to be shared and often Integration Joint Boards (IJBs) and local authorities do not have robust data about the needs of people who are imprisoned.

Access to care and support

The workstream found that eligibility criteria designed to be applied in the community, which are heavily weighted towards physical needs, meant that some people may not be able to access support while in prison. These could include people with complex needs, including chronic but low level mental health and substance use, or with cognitive decline who are unable to work, attend education, or maintain relationships. Also, whilst there are a number of wellbeing services in prisons, these have generally arisen organically rather than being based on strategic needs assessments and commissioning plans. Although there are some peer support opportunities and listening services in prison, opportunities to access informal support opportunities similar to those in the community are much reduced e.g. support from families, friends, libraries, and churches. The workstream identified the need for any future work on access to care and support to explicitly recognise the impact of the prison environment on the availability of informal and third sector support, and to take into account the capacity of individuals in prison to access such support

Services in prisons often seek to be similar to those in the community, for example in terms of access to healthcare. However the limited choice and restricted access to care services in prison can mean this is more difficult to achieve, making equivalence unachievable or unsuitable. Achieving equivalence may mean access to services being considered in a different way in custodial settings.

Relevant Independent Review of Adult Social Care Recommendations

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 19: The National Care Service should oversee social care provision at national level for people whose needs are very complex or highly specialist and for services such as prison social care that could be better managed on a once-for-Scotland basis.

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

What we propose

The Independent Review of Adult Social Care recommends that the National Care Service (NCS) should oversee social care provision for people in prison and be responsible for the planning and delivery of care in prisons,

This will also form a part of work to create a single, outcomes focused approach to care and support which stretches from prevention and early intervention through to acute and specialist provision.

Questions

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

BSL Version of Question 43

• Yes
• No

Please say why.

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

BSL Version of Question 44

• Yes
• No

Please say why.

Alcohol and Drug Services

How it works now

The responsibility for the provision of specialist adult drug and alcohol service provision is entirely delegated to the integration authority.

The services provided are generally a combination of clinical services, social work and social care provision. Elements of social care provision will be contracted from the third sector. Services will have varying degrees of integration and joint working. In addition there can be community, voluntary and mutual aid support for people.

People with severe and enduring issues with alcohol/drugs will often have other complex issues that overlap with mental health, children's services, housing, and justice as well as physical health issues. There is variation between different areas as to whether justice and children's services are delegated to the integration authority.

Specialist services for children who use alcohol/drugs would generally be provided through children's services rather than the specialist drug and alcohol services.

Each local authority area has an Alcohol and Drug Partnership (ADP). The ADP has a responsibility for strategic planning and performance across the spectrum of drug and alcohol issues including education, prevention, early intervention, treatment, support, recovery, and licensing/legislation. ADPs membership is made up from various public services, including the NHS, the local authority, Police Scotland, Scottish Prison Service, and the Scottish Fire and Rescue Service, plus third sector organisations and community representatives. There will be variation in chairing arrangements for ADPs and some have independent chairs. ADPs also have a role in some areas supporting the public protection agenda and reporting to Chief Officer Groups, which bring together the chief executives of relevant organisations. Governance, finance and procurement is provided via the integration authority.

Issues and problems

People with drug and alcohol issues often have multiple complex needs that span a range of health and social care issues. They may have experienced multiple adverse childhood events and be deeply affected by trauma which can make engagement and change difficult. Drug and alcohol issues can be chronic and relapsing meaning that people may need long term and/or multiple episodes of treatment, care, and support.

It can be difficult and complicated to create individual care plans for people across systems and ensure care is joined up across complex systems. For some, multiple services may need to "wraparound" people at acute stage and many people face stigma which can prevent them seeking help or progressing towards recovery.

Governance and accountability for alcohol and drugs services is challenging given that services range across the NHS, local authorities, and third sector organisations.

Many stakeholders feel that the system is focussed on treatment (which is mainly delivered by the NHS and local authorities), with recovery and wider support services (delivered by the third sector) not given the same level of priority. However, evidence shows that earlier connections to recovery services dramatically increase the likelihood of successful treatment. There is also evidence that many people can fall through the gaps of the system, for example when moving from hospital to the community, from treatment to recovery.

There is a need to ensure a "no-wrong-door" approach to accessing support for drug and alcohol issues, as the initial contact may not always be through specialist drug and alcohol services. Additionally, some elements of care may fall out with the remit of those services, such as housing/homelessness support, justice, children's support, welfare, hospital, and acute care. Crucially as part of this approach, mental health and alcohol and drug services must be better connected to ensure that people presenting with multiple complex needs are not excluded from treatment and care at either of these services.

There is a need to develop a trauma informed workforce, with skills and knowledge across specialist and non-specialist services, and able to work with people with multiple complex needs presenting for help.

What we propose

People with problematic substance use are often one of the most marginalised in society, and those with lived and living experience of problematic use of substances should be included in a collaborative, rights based and participative approach to the design and monitoring of services. This should recognise that additional support may be needed to facilitate full participation.

We expect that Community Health and Social Care Boards (CHSCBs) will continue to be key partners in ADPs, taking the place of Integration Joint Boards (IJBs) and will continue to provide the governance, finance and procurement functions for them. However, we will consider whether changes can be made to make ADPs more effective and whether they should become part of the National Care Service (NCS) nationally and part of CHSCBs. We would like to hear your views on what changes might be helpful.

We are also considering whether it would be more effective for the NCS to commission specialist provision, such as residential rehabilitation services, on a national level. The aim of this would be to increase accessibility of rehabilitation programmes, and aid in developing good practice on referral pathways, and ensuring funding models are clear and deliver value for money. We are also interested in views on whether other alcohol and drugs services might be better organised on a national basis.

Questions

Q45. What are the benefits of planning services through Alcohol and Drug Partnerships? (Tick all that apply)

BSL Version of Question 45

• Better co-ordination of Alcohol and Drug services
• Stronger leadership of Alcohol and Drug services
• Better outcomes for service users
• More efficient use of resources
• Other opportunities or benefits - please explain

Q46. What are the drawbacks of Alcohol and Drug Partnerships? (Tick all that apply)

BSL Version of Question 46

• Confused leadership and accountability
• Poor outcomes for service users
• Less efficient use of resources
• Other drawbacks - please explain

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

BSL Version of Question 47

• Yes
• No

Please say why.

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

BSL Version of Question 48

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

BSL Version of Question 49

• Yes
• No

Please say why.

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

BSL Version of Question 50

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

BSL Version of Question 51

Mental Health Services

How it works now

Mental health services include a wide range of activities and professionals, including primary mental health services, Child and Adolescent Mental Health Services (CAMHS), community mental health teams, crisis services, mental health officers and mental health link workers.

Some elements of mental health services are currently delegated to Integration Joint Boards (IJBs), however this is not consistent across Scotland and there is significant variation in terms of management arrangements and performance.

Issues and problems

The current model can cause difficulties for staff working within services and service users. It is also difficult to operate a consistent financial allocation model to support improvement. As a result there is evidence of inconsistent integration of mental health care and social care to the detriment of service users.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 20: The National Care Service's driving focus should be improvements in the consistency, quality and equity of care and support experienced by service users, their families and carers, and improvements in the conditions of employment, training and development of the workforce.

The review specifically includes support for people with mental health problems in its scope. It states that mental health accounts for £187 million out of £3.8 billion spend on adult social care.

What we propose

We propose that appropriate elements of mental health services should be consistently delegated to the National Care Service. Responsibilities within and between organisations should be consistently applied in all parts of Scotland and understood by all.

Questions

Q52. What elements of mental health care should be delivered from within a National Care Service? (Tick all that apply)

BSL Version of Question 52

• Primary mental health services,
• Child and Adolescent Mental Health Services,
• Community mental health teams,
• Crisis services,
• Mental health officers
• Mental health link workers
• Other – please explain

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

BSL Version of Question 53

National Social Work Agency

How it works now

There is currently no national oversight or support for social work. Social work is dynamic and complex, requiring professionally qualified social workers to work alongside people and families during their most challenging times. Making sure there are enough social workers, and that they have high quality training and continuous professional development, is therefore essential to improving people's experience of social care.

In Scotland, there are currently around 10,000 registered social workers, with around 6,000 working in frontline services. The workforce relies on the supply of newly qualified social workers - approximately 500 per year. Most social workers are employed by councils.

Key to the professionalism of social work is education, continuous professional development, and improvement, all of which are supported and provided by several organisations and agencies.

Issues and Problems

There is no single national body tasked with having oversight and leading social workers' professional development, education, and improvement. Terms and conditions are set by individual employers, resulting in local variations in social workers' pay and grading.

Currently, social work is funded to deliver its statutory functions, but the workforce is facing increasing pressure from a growing demand for its services, for example addressing the population's growing mental health issues. The pressure on the workforce also means that their focus is primarily on people in crisis or with significant needs, with much less time spent on preventative and anticipatory work. This increasing demand on social workers makes workforce planning challenging, and restricts opportunities for professional development. Each year, securing over 1,000 social work student placements is reliant on employers' capacity and would benefit from national workforce planning.

As several organisations advocate, deliver and advise on social work education, development, and improvement and research it has not been possible to scale up good practice.

Relevant Independent Review of Adult Social Care Recommendations

Recommendation 45: Establishing a national organisation for training, development, recruitment and retention for adult social care support, including a specific Social Work Agency for oversight of professional development. The current role, functions and powers of the Scottish Social Services Council should be reviewed and appropriate read-across embedded for shared and reciprocal learning with the NHS workforce.

The Independent Review of Adult Social Care (IRASC) also highlighted that training and professional development needs to be appropriately resourced.

What we propose

We propose that a National Social Work Agency (NSWA) should be established, in line with the recommendation, alongside a centre of excellence for applied research for social work to support improvement activity (see Improvement). Both should be part of the National Care Service (NCS) infrastructure and inextricably linked to wider planning and improvement activity.

The NSWA would have national oversight and leadership over social work qualifications, workforce planning, improvement, training, continuous professional development and pay and grading within a national framework. It would invest in and raise the profile of social workers throughout the NCS and partner organisations, ensuring parity with other professions.

Questions

Q54. What benefits do you think there would be in establishing a National Social Work Agency? (Tick all that apply)

BSL Version of Question 54

• Raising the status of social work
• Improving training and continuous professional development
• Supporting workforce planning
• Other – please explain

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

BSL Version of Question 55

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

BSL Version of Question 56

• Yes
• No

Please say why

Q57. Which of the following do you think that a National Social Work Agency should have a role in leading on? (Tick all that apply)

BSL Version of Question 57

• Social work education, including practice learning
• National framework for learning and professional development, including advanced practice
• Setting a national approach to terms and conditions, including pay
• Workforce planning
• Social work improvement
• A centre of excellence for applied research for social work
• Other – please explain