The Future of Social Care in Scotland

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May 2017

This paper is presented as an accompanying discussion paper to Jo Armstrong’s analysis ‘Scotland’s social care sector: The financial evidence that is driving change.’

Introduction

Scotland’s vibrant third sector works across a number of areas, from employability support to research, and has a positive impact on the lives of Scotland’s most vulnerable individuals and communities. 84% of Scottish households used a charity last year and figures show that voluntary organisations hold a position of trust in Scotland. With 138,000 employees and a turnover of almost £5 billion, the third sector is pivotal to people in Scotland and the Scottish economy.

A key concern for SCVO is the sustainability of the sector in Scotland. Social care amounts to over a quarter of the third sector’s turnover and 34% of voluntary organisations in Scotland are involved in social care-related activities. Of the ten charities that receive the most public sector funding in Scotland, nine are health and social care providers. Sustainable social care is therefore crucial to the sustainability of the third sector as a whole.

At the level of individual practice, there is much good being done to help people live fulfilling lives. Nevertheless, rising demand for social care services and declining resources, projected against changing demographics and political turmoil present particular challenges for basic sustainability. As the third sector looks to participate in such discussions, SCVO is keen that the sector has a clear understanding of the challenges, and opportunities, within social care.

In this context, Jo Armstrong has been commissioned by SCVO to conduct a financial analysis of the social care sector. Jo is an independent business economist and honorary professor at Glasgow University Business School who also has great experience in our sector having served as a Trustee, Chair and Board member in various third sector organisations involved in social care.

The aim of this work is to stimulate debate around the sustainability and future organisation of social care in Scotland. Whilst the financial analysis presented uses publicly available data on both charities’ finances and public sector budgets from pre-2016, the report raises key questions around future funding models, the purpose of social care and the organisation of the sector which we argue remain relevant and so worthy of debate.

As the social care landscape goes through a somewhat protracted period of change and as Scotland faces a critical decision around how to organise social care in the future, SCVO believes there are some key environmental concerns worthy of consideration. Some of these factors are outlined within this discussion paper.

Social Care in context
It is impossible to discuss social care policy and care delivery in isolation from other policy and social concerns. For example, the devolution of welfare powers and pre-existing commitments in the realm of health policy will impact social care design and delivery. In this way, a whole-system approach is required, ensuring alignment with other policy areas such as social security while also considering what constitutes “social care”.

The launch of the Shared Ambition report in July 2016, co-signed by a number of key civil society organisations, has stimulated some important conversations around Scotland’s model of social care. Adopting a social model definition of disability, the report advocates for a sustainable human rights based approach to social care across Scotland. The Report promotes a new narrative ‘which sees social care support as an infrastructure investment in the social and economic wellbeing and development of society as a whole; not the spiralling cost of an ageing society; nor merely the provision of ‘healthcare in the community’. In line with this, we believe that social care is fundamentally a social justice issue.

Responsive, high-quality social care is a crucial tool in conquering societal ills such as loneliness, isolation and the disability employment gap. A positive step would be to think of social care in terms of rights and entitlements, with the overriding purpose of enabling people to live fulfilling, independent lives, rather than merely ‘looking after people’. Indeed, there remains a need for a frank, open conversation around the definition of social care.


Personalised, user-directed support


Self-directed support (SDS) has yet to become the default option for social care in Scotland. This is despite the Social Care (Self-directed Support) (Scotland) Act 2013 meaning that everyone eligible for social care support has the right to choice, control and flexibility to meet their personal outcomes. Without such choice and control, social care will continue to be ‘done to’ individuals, rather than in collaboration.

The Learning Disability Alliance Scotland surveyed people with learning disabilities and found that on the question of control, 62% of those with SDS felt their views were included in their care, compared to 39% of those without an SDS plan. Audit Scotland are also conducting a follow-up audit of self-directed support, due for publication in the summer, which will assess outcomes through seeking evidence from people themselves about their experiences of SDS.
There is no question that there remain ongoing issues around organisational change. While the majority of stakeholders agree that there needs to be change within the system of social care, there remains some difficulty around leadership and buy-in. SDS has also suffered as ownership of development and implementation has been somewhat caught up in wider tensions between central and local government so SDS has not necessarily been pursued as a priority. As such, the promotion of SDS has not necessarily led to increased understanding among those receiving care, let-alone the wider public.

Social care can, and must, be a gateway to the realisation of other, broader human rights – including the right to active citizenship, employment and choice and control. The renewal of social care standards based upon human rights is a positive step in this area. However, there must be concentrated efforts to raise awareness of these rights if individuals, and their families, are to be empowered to make informed decisions about their care

Delivery of social care is complex and involves small, medium and large providers across the private, public and third sector. From national providers, to bespoke community-led interventions, all of these organisations have a stake in driving better services and improving the ‘system’ of social care in Scotland. Within a system that is based on personal choice, it is likely that there will be a place for a multitude of providers, across various sectors. Indeed, Section 19 of the SDS Act gives local authorities a legal duty to promote a variety of providers of support, and the variety of support provided by it and other providers.

Health and Social Care Delivery Plan

The recently published Health and Social Care Delivery Plan aims to pull together different activities and highlights that different programmes of change cannot work in isolation from one another. Voluntary Health Scotland have published a detailed briefing on the Plan which outlines key points for voluntary health organisations to consider.

A key source of disappointment is that the plan remains health-centric, in terms of language, focus and energy. This is despite the fact social care is the answer to many of the issues facing healthcare and apparent emphasis on prevention and early intervention. In many ways, this is testament to a wider pattern whereby genuine integration has not yet transpired with health and social care continuing to operate in somewhat separate spheres. Moreover, the third sector is not given emphasis as a key player within this sphere and there remains a lack of emphasis on co-production within services.

Plans pertaining to prevention and self-management of their conditions continues to do so through a narrow clinical intervention lens. While there is welcome discussion around shifting resources to the community, there appears to be little acknowledgement of community resources in the sense of third sector organisations, community organisations and pre-existing community infrastructure. These resources support individuals with the direct, or indeed indirect, aim of achieving positive health outcomes.

This Plan does not appear to fully acknowledge the evolving financial context. While shifting focus to prevention will facilitate longer-term savings, this will not be enough to solve the immediate financial concerns for the sustainability of care, as detailed in Jo Armstrong’s paper.

Local Government Commissioning

The majority of adult social care is delivered via local authority commissioning within a highly competitive and price sensitive market of third sector and private providers. Commissioning processes are often seen to be prioritising professional inputs rather than personal outcomes and the current practice of commissioning by competitive tendering appears to be at odds with the underlying values of personal choice and control. While some local authorities have explored alternative, flexible means of commissioning, traditional commissioning remains dominant, with continued use of time and task. Encouraging the sharing of best practice and the ceding of control over audit will enable greater innovation in social care provision.

There has been some research around the importance of commissioning. For example. Julian Corner, Chief Executive of Lankelly Chase, has noted that commissioning models and the replacement of public delivery model simply with VCO providers may lead to the same services being delivered by different providers, ultimately leading to voluntary and community organsations to lose their unique perspectives. This may undermine the third sector’s ability to challenge those who commission services because they are afraid of losing out on contracts and funding

Within the 2016 CCPS Business Resilience Survey 60% of respondents answered yes to the question ‘have you abstained from or withdrawn from a procurement process in the past year?’ and nearly 20% of respondents noted that they had withdrawn from current contracts because they were no longer financially viable. Handing back services, due to factors such as low hourly rates or a lack of resources, may become more common as issues around sustainability come to the fore. This impacts the consistency and quality of services individuals receive and also has important implications for staff morale.

How you contract shapes what is delivered. This is not to say that merely redesigning procurement processes will be enough to ensure sustainability and personalisation, but commissioning models can be better positioned to promote innovation. Resource constraints can encourage standardised services and insecure funding arrangements can lead to moves away from innovative projects.

Fair work


The UK Government’s National Living Wage and the Scottish Government’s ‘real’ living wage commitment for all social care staff, although welcome, represents a particular risk for the budgets and operations of social care organisations. There are also ongoing discussions around qualifications, full payment of sleepovers and travel between clients and, as yet, local authorities are not applying appropriate weight to fair work in the commissioning process and contract evaluation.
Pay is only one aspect of the fair work agenda and consideration must also be given to working conditions. This is particularly important if the image of social care as a career is to be improved. Social care is a feminised sector, with women overrepresented within the profession and there must be gendered considerations when assessing working conditions. Tackling this occupational segregation across the health and social care must look at men’s under-representation in caring professions, as well as overcoming the barriers to career progression and leadership for women. Engender’s Sex and Power in Scotland 2017 report also found that while 71% of the NHS workforce is comprised of women, only 38% of NHS health board chief executives are women and only 30% of Health and social care integration joint board chairs are women. This ultimately represents a significant gender gap between staff grades across NHS Scotland.

Unison have highlighted some key staffing questions which require attention if social care work is to be seen as a secure, fulfilling job where employees have an effective voice. It is clear that recruitment, retention and reward are crucial debates for the sustainability of social care as the 2016 Business Resilience Survey highlighted that 74% of respondents had experienced ‘a lot or some difficulty with recruitment’.

There are some concerns that self-directed support will have an adverse effect on the workforce – given the need for flexibility perhaps leading to increasing fragmentation of working time, the advent of split shifts and the need for training. Research by Eccles and Cunningham, commissioned by CCPS, found some evidence of work intensification, demanding more for the same or less from employees since the advent of SDS. The qualitative data also revealed how realising greater employee flexibility led to a number of tensions in employment relationships. These concerns have to be assessed and addressed to ensure there is a responsive, motivated workforce to deliver high-quality care.

Community Support
An objective within the Shared Ambition Report was to support disabled people to participate in and contribute to Scotland’s economic, social, civic, and cultural life as equal citizens. Community support assists the realisation of this objective and improves quality of life. Consequently, a pivotal question is how we can promote and endorse ancillary community support which has an important role to play in prevention, well-being and quality of life. By this we mean those community support initiatives such as the Food Train, Care and Repair and lunch clubs.

In promoting and enabling independent living, such community organisations are an important piece of the social care puzzle. While there are a plethora of organisations working in this sphere and much of the infrastructure is in place, much of this sector is precariously funded and not sufficiently within the purview of Integrated Joint Boards. In addition to providing services that work alongside clinical services, bespoke community interventions should also be viewed as a valid option for support under the principles of SDS.

The ability of community approaches to promote good outcomes and achieve efficiencies should therefore be explored in more detail by Scottish Government. Despite emphasis on community support and community resources in the aforementioned health and social care delivery plan, this appears to remain focused on formal, statutory care settings, rather than untapped community resources. As outlined by Voluntary Health Scotland, it is important

that GPs and multidisciplinary teams within GP practices utilise the services and support

provided within the community by third sector organisations. It must also be recognised that third sector organisations provide support with social, environment and economic determinants of health.

These bespoke third sector interventions have real preventative character and if the Scottish Government’s focus on early intervention is to have real traction, the value of community interventions and resources must be recognised. Funding for such initiatives must, however, reflect their value in being sustainable, fair and have longevity. As pledged in the 2016 SNP Manifesto, longer term funding for the third sector would be of great assistance here.

Unpaid caring
Additional networks of caring, mostly unpaid and within community networks are also vitally important, particularly given the tightening of eligibility criteria within certain local authority areas. Scottish Government should not rely on unpaid care at the expense of funding and investment in statutory care. However, resources and support should enable individuals to choose to care for loved ones, or to be cared for by loved ones, if that is their personal choice. For this to transpire, it is clear that Scottish Government must support carers, promoting carer’s rights and wellbeing.

The Scottish Government research from 2015 estimates that there are approximately 759,000 carers aged 16 and over in Scotland which represents around 17% of the adult population. This means that there are many more unpaid carers providing support than those in the paid social services workforce. Carers UK recently estimated the value of unpaid care in Scotland to be £10.8 billion. The Census also found that 44% of unpaid carers provided 20 or more hours of care a week, which represents a 7% increase since 2001.
Unpaid carers must be involved in developing local frameworks for support, ensuring a flexible approach to care and promoting the voice of unpaid carers. At present, unpaid carers are not included within Strategic Commissioning Plans and there are concerns that carers on the Integrated Joint Boards are not being supported to fulfil their role in the sense of representing carers’ interests more broadly, rather than individual experience and anecdotal evidence.

More generally successfully achieving full integration of health and social care, meaning that appropriate care should be available to the individuals they are caring for, will also be a source of support for unpaid carers. Another important legislative development will also be the implementation from April 2018 of the Carers (Scotland) Act which improves both the recognition and rights of carers in Scotland. Under this legislation, local authorities will have to provide carers with information and will have to develop and publish local carer strategies.

Women are also grossly over-represented in unpaid caring roles, meaning that policy is this area is an important consideration for the economic and social participation of women. Research has found that at least 59% of unpaid carers in Scotland are women and 74% of Carer’s Allowance claimants are women. There has been little disruption of the social and cultural expectations which lead to women being twice as likely to give up paid work in order to care. There must be attempts to introduce measures to incentivise employers to help workers with caring responsibilities including flexible working patterns and continued efforts to increase Carer’s Allowance and related benefits. The levels at which benefits are paid is also only one piece of the puzzle, as accessing the benefits and support remains problematic for many carers.

Conclusion

When assessing the medium to long-term view of the sustainability of the sector, there is not a single proposition for the future of social care in Scotland. There are a multitude of options and a number of players within social care, including those receiving care, providers, the wider third sector, Scottish Government and Local Authorities. There should be attention given to the spectrum of social care, from prevention, to crisis intervention and the everyday support which promotes wellbeing and positive outcomes. We believe that there must be a wide-ranging debate on the options for guaranteeing a sustainable future for social care.

Sustainable social care is not just about improving the sustainability and practice of individual organisations alone, but rather promoting a whole-system approach to sustainability. This means assessing the boundaries of what we determine to be social care and promoting linkages across the overlapping systems of social security, healthcare and employability. This also means discussing commissioning, having a frank discussion about how we allocate resources, how we encourage voice and agency within public services and promoting the principles of the Christie Commission.

The key finding from Jo Armstrong’s analysis is that the status quo is not sustainable and neither can it guarantee quality service for individuals. The political, financial and operational environments render it vital that we continue these discussions. For this reason, we’ve included some discussion questions below, designed to stimulate initial conversations. Taken together, we hope that these papers will promote a genuine debate about the future of social care in Scotland.

Discussion questions

The financial analysis, coupled with wider policy concerns, raise numerous questions:

  1. How should social care be organised to better meet the needs of individuals?
  2. To what extent have self-directed support and the creation of the Integrated Joint Boards changed where control lies in the system? If control hasn’t shifted, why not? And where should it lie?
  3. How do you create a system of social care based around the principles of independent living, rather than ‘merely looking after people’?
  4. How do we ensure a future for social care that guarantees choice and control for individuals and a variety of providers of support?
  5. How do we promote the leadership necessary to achieve the ambition of sustainable, personalised social care?
  6. What is the best way to commission social care?

As the only inclusive representative umbrella organisation for the sector, SCVO:

  • has the largest Scotland-wide membership from the sector – our 1,900 members include charities, community groups, social enterprises and voluntary organisations of all shapes and sizes
  • our governance and membership structures are democratic and accountable – with an elected board and policy committee from the sector, we are managed by the sector, for the sector
  • brings together organisations and networks connecting across the whole of Scotland
  • SCVO works to support people to take voluntary action to help themselves and others, and to bring about social change.
  • Further details about SCVO can be found at scvo.org.uk.

CONTACT

Ruth Boyle, Policy Officer
John Downie, Director of Public Affairs

Scottish Council for Voluntary Organisations,

Mansfield Traquair Centre,

15 Mansfield Place, Edinburgh EH3 6BB

Email: ruth.boyle@scvo.org.uk

Tel: 0131 465 7532

Web: www.scvo.org.uk