While sound and fury explodes all around us on NHS spending, spare a thought for the crisis in Scotland's social care system.
Today, I was in parliament for the launch of the Commission for the Provision of Quality Care in Scotland report. The Commission was established by Neil Findlay MSP when he was Shadow Cabinet for Health and Wellbeing with the aim of reviewing how we can improve the way adult social care is delivered. It was Chaired by David Kelly who was a Director of one of the first Community Health and Care Partnerships in Scotland and brought together all the main stakeholders.
The strength of this Commission and the earlier one on health inequalities is two fold. Firstly, they address issues that don't get nearly enough attention in the Scottish health debate, that at times seems obsessed by A&E waiting times to exclusion of all else! Secondly, Neil was very clear in his remit that he didn't just want another analysis of the issues (something we are very good at in Scotland), he wanted solutions. Even if the solutions might be politically difficult.
The report starts with a stark assessment of the current position. We have an ageing population with an increase in multi-morbidity and long term conditions. In disadvantaged areas the most common co-morbidity is mental health and this combination has a strong association with health inequalities and negative outcomes for individuals and families.
These additional demands bring with them associated costs. The report estimates a real term increase of up to £2bn per annum will be required by our health and social care system by 2025. With a small growth in the size of the overall population this is likely to place an increasing tax burden on the working age population. The recent IPPR report reinforces this point.
During the years of Tory austerity the Scottish NHS budget has had a degree of protection at the expense of other public services including social care.This approach has failed to recognise the inextricably linked relationship between acute hospital care and care in the community. The consequences can be seen in the numbers of patients blocking beds in our hospitals and a £5million increase in the amount councils are having to generate from charging income for social care in order to compensate for the financial shortfalls.
The report describes the complex and frankly inadequate ways the quality of care is assessed in Scotland. UNISON Scotland's 'Time to Care' report starkly set out the views of care staff over the quality of care they are forced to deliver. While in the main health and social care services are provided good levels of quality, there are still too many examples of poor quality. The report concludes that general trends about quality cannot be ignored. In particular, the connection between the quality of staffing, working conditions, and quality of care is a matter of primary importance.
The workforce chapter seeks to address a key component of this. The Commission recognises that more than anything else, the payment of the living wage and a general improvement of terms and conditions will be required to deliver a social care workforce consistent with our aspirations for quality care. This view is shared by the evidence submitted to the Commission from both trade unions and employers across the public, private and voluntary sectors. The contracting race to the bottom in care provision has to stop.
Since the report was written the social care crisis has if anything got worse and today councils and providers in England are making similar points. We have residential and homecare providers in in very difficult financial circumstances, drawing on reserves and some are struggling to meet even day to day cash flow. Others have significant vacancy rates and increasing staff turnover. Social workers in care of the elderly teams report that it is becoming increasingly difficult to find a provider to deliver care packages in some parts of the country.
Pay is but one element of fair work. The Commission commends UNISON's Ethical Care Charter that includes the wider considerations that commissioners of home care should account for when contracting. These include training, induction, travel time, ending zero-hours contracts and most importantly ensuring that there is time to care.
The Scottish Government's standard response to concerns about social care is to refer to the new Integrated Joint Board's that aim to provide a seamless care service. While the Commission supports this approach, it recognises that this structural change will not in itself be enough. The recent Audit Scotland report confirms this. Despite the Kerr report and much talk about preventative spending, we have not been able to break the public perception that everyone should have a district general hospital within ten minutes of their house – nor the political pressure to satisfy that thirst.
The Commission argues that a top-down approach to the commissioning of services will fail to deliver responsive care and support. The report places an emphasis on getting locality planning right building on the knowledge and capacity of local people about their own wellbeing. It also recognises that best practice needs to be supported and rewarded. Equally, there is a need to work with poorly performing locality teams to improve outcomes. We need to recognise that not all differences in outcomes are down to differential resources. It can reflect poor leadership, organisation and bad practice.
Housing provision also needs to change if we are to address the needs of an ageing population. All too often, a person will move from their family home into a care home via a period in hospital.This is partly because of the lack of suitable alternatives at local level. We need to build new, affordable and sustainable housing, with a range of house types and sizes that encourages mobility in the housing system and enables downsizing for those that wish it. Housing support services currently play a small, but significant, role in supporting older people to remain living at home and needs to be expanded.
A key recommendation of the Commission is that we fundamentally rearticulate the basic social contract between the citizen and state based on the principle of reciprocity.That people contribute to the wider social good through payment of tax and direct contribution to care and support – and in return people receive high quality care and support when they need it and irrespective of their financial circumstances. This means addressing the current differences between services free at the point of use such as healthcare and some social care, but not for those under the age of 65.
As such, the Commission arrives at a new and more robust social contract: the responsibility of the state is to ensure that citizens with personal care needs receive that care free at the point of use; and that citizens are otherwise responsible for their daily living costs and additional support requirements, funded from personal wealth or income, or for those citizens who are less well off, from welfare support.
Finally, the Commission addresses the question of funding. A properly funded and organised social care system would actually save money. For example, a bed in a District General Hospital costs in the order of £2,500 per week, as compared with £500-£800 per week for a care home and even less for home care. The Commission points to work done elsewhere in the UK on the options for addressing the funding gap, something we have simply ducked in Scotland. A national conversation needs to be informed by a detailed examination of the spending gap and how that might be funded. The Commission makes no claim that its work is sufficiently detailed to be a definitive statement on this issue. However, they do say that it is sufficiently large that it cannot be wished away or ignored.
The value of this Commission report is that it does more than simply analyse the scale of the problem, important though that it is if we as citizens are to grasp the importance of social care. The Commission goes much further in describing what a quality care might look like and how it should be delivered. It also doesn't duck the need for a new social contract and the necessary conversation about funding.