Social care support reform: summary of discussion paper responses

3. The themes that emerged from the responses to the questionnaire

3.1 Overview

This section of the report presents a review of the themes across all of the responses and all of the questions.

3.2 The themes

The social services workforce

Aspects relating to the workforce were one of the most common and repeated themes across the stakeholder responses. There was a consensus as to the challenges the system is facing in relation to the current workforce, and the outlook moving forward. Responses typically focused on issues related to:

• challenges to recruit sufficient staff to meet the projected care needs of the population;
• ensuring staff remain in the sector, both in terms of making sure it is an attractive career and supporting their wellbeing and resilience;
• ensuring that staff have access to and can attend training, learning and development opportunities that equip them with appropriate skills, for example, for outcomes-based support planning;
• widening access to training and development opportunities (for example to Personal Assistants), and training for people or carers managing social care budgets (for example around employing Personal Assistants); and
• ensuring payment of the Living Wage to social care workers.

A few responses expressed concerns about the potential impact of the UK's exit from the European Union on the recruitment and retention of social care staff. One response suggested that this would disproportionately affect rural and remote areas.

One response discussed workforce issues in the context of what they regarded as discrepancies between externally contracted staff and staff employed by Health and Social Care Partnerships or local authorities:

"The struggle to recruit staff to fill rotas is the most pressing issue faced by social care providers. Increased resources are clearly required to achieve greater equivalence between public authority and externally contracted services. There are concerns that the National Workforce Plan [the National Health and Social Care Workforce Plan for Scotland] may not equally benefit or include third and independent sector providers." (quote from a third sector organisation)

Topics relating to workforce were listed repeatedly as areas of concern within the current social care landscape. They were often also integral to people's views on what the shared vision for social care should be. Tackling or resolving these issues were often regarded as a means of improving social care currently and into the future. Failing to address the highlighted issues was often referenced as one of the major risks or concerns for the success of the programme in supporting reform of adult social care.

Funding/investment

Comments relating to funding and investment were common and repeated across the stakeholder responses. While responses varied slightly in their views of which areas require investment in particular, overall, there was a call for an increase in funding in social care across the board. Some responses specifically discussed exploring new models for funding social care.

Responses that referenced funding discussed what they regarded to be a shortage of adequate funding in social care currently, and also in regards to maintaining support and services into the future. Some specifically commented on a need to ensure that there is adequate funding to properly enable self-directed support approaches. Some also suggested moving away from short term funding for projects around self-directed support to longer term funding, to allow projects to build success and sustainability.

Some responses discussed the challenge of balancing multiple competing priorities when making decisions locally on how to distribute funding between different supports and services. In this context, some mentioned challenges in securing sufficient resources for social care in the absence of 'ring fencing' of funding for adult social care (or ring fencing in general) within local budgets. Also, one response described what they felt overall to be a "period of cuts to services, increasing care charges and changes to disability benefits", with "austerity" generally having a negative impact on the social care support that people experience (quote from a third sector organisation).

Some responses felt that concerns around budgets, or overall a lack of funding in social care, were the main factors determining the options available to people accessing or trying to access care and support in the current system. Some also felt it was impacting on the development and implementation of national and local policies. The responses approached this in different ways. Some suggested this was necessary to ensure public funding is used in the best and most equitable way. Others described it as an indication of not recognising the real level of need for social care in Scotland:

"There needs to be recognition that choice and control of care do not always offer best value, choice can be limited where resources are limited. A light touch audit for creative spend [of personal budgets for social care] needs to be balanced with accountability for [overall Health and Social Care Partnerships'] budgets." (quote from the public sector)

"There is an evident challenge in securing agreement between commissioners and providers on the funds required to deliver the care sector our country needs, and both groups are facing acute budgetary pressures. In a context where the sector as a whole is underfunded, this will continue to be a difficulty and potentially a barrier to achieving the reform which is required in the delivery of care services." (quote from a third sector organisation)

"there needs to be a better understanding of how adult social care has been and will be impacted by the savings programmes in local authorities and the budgets currently available locally to address demographic need." (quote from a third sector organisation)

The issue of funding often arose in the context of a discussion of other topics (e.g. increase in wages for staff) as well as a general comment in regards to the value placed on social care overall.

Increases in funding/investment were regarded as necessary in order for the programme (and the social care system overall) to achieve its aims and objectives. Moreover, some expressed specifically a view that investment in social care would produce better outcomes overall (it was assumed that this referred both to outcomes for people and system-level outcomes). One response from the public sector said that:

"Delivering better outcomes (even better health outcomes) can only be achieved through investing in social care because health and social care should be indivisible".

Throughout the responses that discussed funding, there was consensus on the need to have a "full and frank" discussion about funding, how resources are currently allocated and how they should be allocated moving forward, and that this had to look beyond social care. Some responses tied this to a wider discussion with the general public about social care:

"A full and frank debate is required on funding social care and health, that fully supports the integration and transformation agenda. The current process that does not ring fence funding for health and social care places unacceptable pressures on IJBs [Integration Joint Boards] should full grant funding not be released by the receiving authority, i.e. local government." (quote from the public sector)

"In the long term, social care in Scotland needs to be put on a sustainable footing to ensure that future increasing need can be met in a way which upholds people's human rights and enables them to continue to participate as active citizens in our society. This requires an agreement not just between the different levels of government and providers from different sectors, but also amongst the people of Scotland, about how social care should be funded and organised, and what constitutes a fair contribution from the different actors in the social care process. This needs to be considered alongside a similar assessment of how our health service functions in the long term. We need as a country to agree our responsibilities to and our expectations of each other, and begin to create both a culture and a legislative framework to enable that." (quote from a third sector organisation)

"[there needs to be] an honest appraisal of the actual cost of care and support and how this is funded]. This includes an understanding of the real 'best use' of public resources. This means a whole system approach to commissioning, procurement and delivery so that problems in the inter-relationships between parts of the system can be identified and resolved. This includes politically sensitive considerations such as reviewing the cost and quality of in-house services; understanding the time and resource costs of competitive tendering and addressing the toxic system effects that result from increasingly tightening eligibility criteria." (quote from a third sector organisation)

One response from the public sector also mentioned funding in relation to the ability to focus more on preventative care and support. They suggested that mechanisms for Health and Social Care Partnerships to plan resources over a longer term would increase their ability to invest in preventative approaches:

"[We need] Budgetary processes that take a more long-term strategic view, so that local authorities and IJB's [Integration Joint Boards] can set in place 3 – 5 year plans that are more outcome focused, that allows for development of early intervention and preventative approaches, in addition to meeting high need."

Coordination, collaboration and co-production

A recurring theme across responses was the view that there is a need for greater co-operation, communication and co-production within the social care sector, and between social care and wider support and services. People were as concerned with how changes in social care and the wider system were going to be achieved as they were with what changes were going to be achieved. Responses frequently called for greater partnership working both within and between sectors as a whole, as well as between and within different levels of governance and practice (e.g. leaders, frontline workers, etc.). One response specifically mentioned the need for "a parity of esteem"between "government, care commissioners and care providers in developing an approach to the future of the sector" (quote from a third sector organisation).

The theme of coordination, collaboration and co-production was often raised in relation to greater coordination of social care support with NHS services and the wider support and services under the management of Integration Joint Boards. Continuity of care when people enter hospital was raised as an issue, as was the need for greater links between social care and mental health support. One response commented specifically on the need for more effective collective leadership within Health and Social Care Partnerships, between the NHS and local authorities:

"there are still funding issues […] we receive our budgets from two (or in one Partnerships case three) different organisations [that] become embroiled in joint meetings with no joint funding consideration." (quote from the public sector)

A few responses also discussed the theme of coordination, collaboration and co-production in the context of transitions between services and felt that this had been missed from the discussion paper. The transition most often referenced was from child to adult services. However, transitions across care and support in general were also referenced.

A number of responses said the discussion paper wasn't explicit enough about social care being part of a wider support system that a person may access. Two responses felt that the references in the discussion paper to the integration of support and services were misplaced. One respondent commented that:

"While the discussion paper refers to the new landscape of integration, it doesn't adequately seek to integrate the reform of social care with health services and settings." (quote from a third sector organisation)

Social security and housing were two specific areas in the wider system of support and services that people said linked with social care. A central point raised in responses was that "the provision of sufficient, appropriate and accessible housing directly influences the expenditure requirements of social care and crucially the delivery of personal outcomes". Also, that there is a direct impact of access to social security benefits on "means testing, eligibility, employment" (both quotes from third sector organisations). An example was given of how housing and social care needs are being integrated in some local areas, through "the development of different types of housing and support models such as extra care housing and housing with care where people are offered up to 24 hour on site support in their own tenancies" (quote from the public sector).

Collaboration within the delivery of support and services was often discussed as both an issue within the current adult social care system, as well as a potential vehicle for the success of the reform agenda. A few responses discussed the existence of barriers to collaboration, and suggested investigating what is causing them and how to address them:

"[…] The capacity and willingness of agencies from all sectors to set aside commercial or organisational interests to work cooperatively in the best interests of the people they support is a significant resource for change that is not yet fully realised. Many opportunities exist to better develop and capitalise on this, and for collaborative solutions to be generated and delivered 'bottom up' from the sector. […] Barriers to collaboration: The real or perceived imbalance in the status and power of statutory sector partners and voluntary / independent sector providers is felt keenly by providers in many areas and is a barrier to the opportunities for collaboration we set out above" (quote from a third sector organisation)

Others discussed the need for a change in perspective in future collaborative work:

"Meaningful partnership- despite changes in the way we talk about providers and local authorities the sector still feels it is treated as 'part of the supply chain' not as an equal partner" (quote from a third sector organisation)

"Explore how to increase and enhance the role of the Third and Independent sectors in strategic decision-making and strategic commissioning." (quote from a third sector organisation)

"There is a dire need for the independent movement to be resourced to 'spread the word' about SDS [self-directed support], its foundation in the social model and its concept of independent living. Local authorities should resource and encourage peer-advocacy and support" (quote from an individual)

Equally frequent were emphases on the need for co-production in social care policy and practice – specifically, that people affected by decisions should be involved in the decision making process. For example, one response felt there was a need for "greater transparency and accountability around decisions relating to self-directed support, for example decisions on eligibility and individual social care budgets" (quote from a third sector organisation).

Understanding of, and attitude towards, social care

Many responses referred to a need to establish a higher regard for social care within local and national policy and public discourse. These references appeared throughout the answers to the different questions in the questionnaire. A few responses said there was a need to change perceptions of social care, to regard it "as an investment in society rather than as a burden." (quote from a third sector organisation). Responses often described a need to engage with the public in order to raise awareness of the value of social care and the work done by social workers, social care workers, unpaid carers, and others delivering or involved in care and support. Comments often placed social care in contrast to the health care sector/the NHS and suggested an imbalance of esteem, outlook, and priorities. The common view was that health care holds a greater degree of priority and prestige in policy and investment decisions, as well as in public opinion:

"The interface between acute and primary and community health and care needs to be addressed, as there is little evidence of a shift of resource to community, especially when the focus of acute is on addressing waiting time targets and tackling delayed discharge. Reform activity focused on promoting the value and status of social work and social care is to be welcomed." (quote from a third sector organisation)

Two responses made statements around the opportunity to reinforce or raise the status of self-directed support as Scotland's approach to social care. One response said that the 2019-2020 Implementation Plan should be used as an opportunity to "reinforce self-directed support as the mainstream approach for social care assessment, support planning and review in Scotland." (quote from the public sector). The other suggested that the refreshed self-directed support Implementation Plan should include "a statement on the value of self-directed support, emphasising the contribution disabled people and carers make to society." (quote from the third sector).

Data

Aspects relating to data were often repeated as an issue in adult social care. Responses typically referenced a lack currently of "meaningful" measures, or a lack of "quality" in regards the data that is currently collected. Responses said there was a need to have a focus on improving the collection and utilisation of quantitative and qualitative data within social care. This was in regards to both measuring the implementation of self-directed support, as well as measuring the effect of changes in practice on people's experiences of care.

Responses were mixed in terms of how to resolve the issues highlighted. Some responses suggested the development of new measures or metrics, whilst others felt the way forward was more robust adoption or better utilisation of already existing measures. Nevertheless, there was general agreement that changes and improvements around data were integral to adult social care reform.

Some responses discussed the need for better "data logistics infrastructure". Many referred to creating opportunities for greater data sharing between different organisations, to support holistic, multi-faceted care and support. Others mentioned this in terms of improving the way that data is used to understand how the system is performing for people and to support improvements:

"The significance and value of social care data and the potential of tracking pathways through health and social care in identifying systemic pressures, for instance, around delayed discharge should be realised. […] Systems and processes for gathering robust data on unmet need would also prove useful in this context, and their introduction is critical for commissioning." (quote from the independent sector)

A few responses described that the kind of data that is collected, and how it is collected can have an impact on what is valued or prioritised and therefore on practices and processes in the social care system. For example, reporting requirements have impacted on the design of social care assessments and on people's ability to innovate:

"Any national input that supports consistency across different areas in terms of assessment and support planning is welcome. In particular, this input is welcome around expectations in terms of both information gathering and capturing information in numerous key documents. This currently results in duplication of information, and subsequently impacts on frontline staff time and increases pressure on managers to oversee quality assurance. In order to support local reform of the way assessment and support planning is undertaken, there needs to be a commitment to look at reporting requirements, via Census etc. Currently, these requirements make very significant challenges whenever an attempt is made to do things differently, for example when considering different models of care etc. However, specific performance and quality measures should be in place that ensure visibility" (quote from the public sector)

Another specifically said that the type of data that is collected nationally to demonstrate progress needs to change in order for self-directed support to be properly embedded in local social work and social care practice. They felt there needed to be a "shift away" from reporting at national level on hours/days of social care support towards national-level outcomes-based reporting:

"Please develop outcomes focused performance measures at national level, which incorporates the process outcomes and the difference the support has made to the person. […] Shift away from reporting in hours/days and limited number of services which fails to reflect accurate activity. As we strive to embed the personal outcomes approach to practice through creativity and innovation, the outcomes and impact of this is not captured/measured appropriately at national level as focus remains on 'options' and volume" (quote from the public sector)

Evaluation/best practice

Evaluation and best practice were often referenced throughout responses. The need to evaluate aspects of self-directed support (particularly its implementation in practice) was the most often cited. For example, one response defined the importance of evaluation, or monitoring/tracking progress, in terms of being able to provide targeted support in a timely manner to local areas around the implementation of self-directed support. However, a wide array of topics were raised as potential focuses for current and future evaluative work.

Evaluation was often discussed together with the topic of establishing and spreading best practice across Scotland. Again, this was a common focus of comments relating to the implementation of self-directed support. Many responses called for a greater focus on innovative practice, and the sharing of learning/practice across the social care sector. Responses ranged from suggestions to explore and evaluate existing examples of best practice in social care/self-directed support, to the establishments of new networks or forums to assess, establish, and share information and best practice in order to improve practice across Scotland as a whole. However, one response emphasised the need to move beyond merely "highlighting" best practice towards taking steps for the principles and values of self-directed support to be realised in all social work and social care practice, so that "it becomes standard and consistent" (quote from the third sector).

Some responses commented on how spreading best practice would improve people's experiences of social care across Scotland. One raised this specifically in the context of the full implementation of self-directed support across all areas of Scotland:

"Feedback from people with learning disabilities also suggests that there is a mixed picture across Scotland in terms of take up and delivery of self-directed support. Local authorities are obligated to give independent information about self-directed support, but provision across Scotland is inconsistent. While local contexts will always have an impact, this does not seem consistent with the principles of self-directed support. For this reason the national programme should aim to promote best practice of how self-directed support has been implemented, and consider how national oversight and accountability can be improved." (quote from a third sector organisation)

Community development and participation in the community

Many responses saw the community as having an active role in care and support. Supporting and developing this role was a theme that emerged across responses. The majority of references to this topic were in regards to empowering communities or investing in/increasing community capacity to support social care delivery:

"We know that when we put people and communities at the forefront of

planning and developing services and support, the outcomes have greater impact, are more cost effective and the process is demonstrably more person-centred. We also see much more innovative service design. The national programme could further support work with communities, neighbourhoods and people to harness their resources and innovation as well as those of providers and local authorities. We need to invest in practical support which creates capabilities locally and resources communities." (quote from a third sector organisation)

"Invest in approaches which place a value on reciprocity and strong community connections between all formal and informal sources of support. This will encourage joint working, pooling of local assets, opportunities to form relationships, appropriate data sharing and two-way signposting systems." (quote from a third sector organisation)

"In terms of a ensuring an holistic consideration of all related issues and opportunities within the adult social care system, the national programme will need to think beyond the care system itself and look at the strengths, assets and networks that support people in our communities." (quote from the public sector)

Some felt that the national programme provided an opportunity to strengthen existing efforts to move social care and wider support and services in Scotland towards a more person-centred philosophy and practice. One response cited:

"We believe that the potential of this piece of legislation [the Community Empowerment (Scotland) Act 2015] has not been fully explored in the context of social care as it may provide opportunities for local communities to take control of assets and to explore other more creative ways of providing services." (quote from the third sector)

References to community were often tied to other topics (e.g. investment in social care overall, or the linking up of community support with wider social care services). A few responses commented on the need to ensure that the narrative around building 'resilient communities' did not translate to extra 'burdens' being placed on communities without the necessary resources and support. A few responses specifically mentioned concerns around a risk of an increase in the 'burden' on unpaid carers.

Responses also emphasised continuing to work towards ensuring that individuals can receive care in the community, if that is right for them. Community was also often referenced in relation to the role of supported people within their communities. These responses were in agreement that supporting people to participate in their communities has tangible benefits for individuals and society, and should be one of the core objectives of social care and reform.

Balance between national and local approaches

Several references were made in relation to the consistency of processes/care across Scotland. An emergent theme across responses was a desire for greater national focus on particular elements in social care. This theme was often discussed in relation to improving consistency, or learning from a range of perspectives. The common view was that a national focus for adult social care, or elements of adult social care, would bring about improvements and would "help to provide equity of care across the country". This topic was discussed by some in relation to the full and consistent implementation of the self-directed support legislation. Within this discussion was a view by the respondents that the legislation/self-directed support had not been fully/adequately implemented in Scotland, and that addressing this discrepancy would help achieve positive outcomes:

"Robust and consistent implementation of the SDS Act [the Social Care (Self-directed Support) (Scotland) Act 2013] across all areas of Scotland would provide the blueprint for achieving sustained progress towards realising a vision for a modern, dynamic adult social care system." (quote from a third sector organisation)

Responses emphasised, however, that there still needed to be sufficient flexibility for local solutions:

"the national programme should not prescribe the delivery model or state a preferred model for delivery. Every community should be able to develop their own model based on their existing assets, their potential for development and learning from the experience of others." (quote from a third sector organisation)

"we believe there may be some merit in exploring whether the resourcing of social care support should be centralised, but combined with responsibilities on local government to provide an enabling assessment and delivery infrastructure." (quote from a third sector organisation)

Responses raised this topic in different contexts and made a range of specific suggestions, for example:

• establishing national eligibility criteria for accessing social care support, with one response citing this was needed to "increase transparency" and "foster realistic expectations and promote consistent application of individual eligible funding nationally (quote from the public sector);
• introducing a national element of access to/provision of social care, beyond local Health and Social Care Partnerships' eligibility criteria. One suggestion was for this to be through additional funding for local areas demonstrating that they are "embedding inclusive and transparent decision making locally, upholding rights and involving disabled people (and other social care users) in the monitoring and implementation of the Self-directed Support Act" (quote from a third sector organisation);
• establishing national peer learning networks;
• national 'guidelines' for the "standard of care each individual receives" (quote from a third sector organisation);
• taking a consistent approach to social care assessment;
• establishing a national policy for social care charging;
• national expectations for how long the process from social care assessment to someone receiving their individual budget and putting in place support, should be, on average; and
• removing local variation in/conditions around access to self-directed support according to age;
• A national, independent mechanism/function for those delivering and accessing social care/self-directed support to raise concerns;
• creating national, outcome-focused performance measures for self-directed support, incorporating both outcomes for people, and process/system outcomes; and
• exploring centralised funding for social care, among others.

One response from the public sector described a view that a potential benefit of a national approach was that it could "help to set the public's expectations [in a way] […] that IJBs\Councils can't." The response discussed recognising "the challenges and reality of meeting assessed need – availability of care, remoteness of service user and ultimately cost of care.", and felt there was a risk of creating "a culture where entitlement to service comes at any cost".

Person-centred approach

Many responses throughout the questionnaire made reference to the need to place the individual at the heart of the process in social care. This was true irrespective of whether the responses were discussing national policy, local policy and management, or frontline practice. Two responses specifically commented on their concern that "choice and control" for the supported person were not being achieved in the current adult social care system. The responses also commented on the need to ensure that the reform agenda itself takes a person-centred approach.

The common thread across the actions that responses suggested needed to be taken to reform adult social care was that it should be done with a focus on the individual: their views, their rights, their assets, their agency, and their needs. As a result, overall, taking a person-centred approach was a theme that underpinned many of the topics under discussion within the responses.

Prevention

Many responses emphasised the need for there to be a focus in the reform programme on approaches that prevent people from reaching a 'crisis' situation before they receive care and support. This included both 'formal' support and less formal supports, for example community groups:

"[…] highlight the need for longer term wellbeing initiatives which form part of the prevention and early intervention agenda. This is needed if the unsustainable demand placed through lack of early intervention and prevention is to be reduced." (quote from the public sector)

The consensus amongst responses which mentioned prevention as an issue/opportunity to consider, was the need to increase the focus on preventative support and interventions, and the opportunity that the reform programme provides to do so:

"The reform agenda also presents an opportunity to finally achieve a shift of resources towards preventative as opposed to responding to crisis. Common sense suggests this will lead to better outcomes and longer-term savings. However compelling this argument is, preventative approaches have not been routinely adopted. A better understanding is need[ed] of the barriers to progress. Through progressing 'data on social care and how it is used' there is an opportunity [to] present data in the ways that will have the most practical impact on informing planning and commissioning decisions." (quote from the third sector)

"Include the wider context of prevention, low level support, community engagement and the less formal supports e.g. community meal makers" (quote from the public sector)

Some mentioned specific policy and practice initiatives in Scotland that focus on prevention and preventative care, and that there were opportunities for the reform programme to link up with these:

"Focus on Prevention – Initiatives such as the AHP [Allied Health Professional] lead model, Active and Independent Living Improvement Programme, or AILIP [Active and Independent Living Programme] Life Curve are also relevant in the context of adult social care" (quote from the public sector)

One response specifically mentioned the impact of a person's home environment on their ability to remain living independently and as well as possible. This was in the context of local 'Care and Repair' services and opportunities to make adaptations to homes, to support people who are disabled or who are becoming less able than they were before, to live independently at home.