Health and care integration report card - could do better

Audit Scotland tries hard to use building language in their reports, but it was obviously a real challenge when it comes to health and care integration.

Audit Scotland has recently published their assessment of the progress with health and care integration in Scotland. Helpfully, as I was preparing a presentation for an English conference on how we tackle this issue in Scotland. You could be forgiven for missing this report as it came out on the day of the Brexit resignations.

As usual they introduce the report with a helpful infographic which captures the key challenges. Integration Authorities (IAs) manage a huge proportion of the Scottish budget (£9bn) and are supposed to achieve £222.5m of savings - an increase of 8.4%.

The positives are that IAs have started to introduce more collaborative ways of working and there are a number of case studies in the report that highlight best practice. This shows that the system can work, however, yes you knew there would be a but, “there is much more to be done”. 

The building language then starts to break down.

They main problem is that financial planning “is not integrated, long term or focused on providing the best outcomes for people who need support”. This is caused by the financial pressures on health boards and councils, compounded by health boards not including their acute services to the process of budget shift. Long term planning is difficult when budgets are set annually, with little medium term, let alone long term, strategic planning. However, an overall underspend by IAs of nearly £40m, does not inspire confidence either.

This doesn’t mean that there is no resource shift because the ISD cost data published yesterday shows a loss of 429 hospital beds. This data also shows that community services are getting more resources, with only a 0.1% increase in hospital spending as against 4.8% in the community sector. GPs have pointed to the fall in the amount devoted to GP services, but this may be related to service redesign. Either way, while there has been some shift from acute to community, progress is slow because of the overall financial position. 

The report also highlights a lack of collaborative leadership and strategic capacity, not helped by a high turnover in IA leadership teams and squabbles over governance arrangements. Cultural differences between partner organisations is another barrier to achieving collaborative working along with the necessary skills to work in partnership. This was predicted, and has been a problem all over the world (see Petch et al) with care integration.

Another lesson from the international evidence is that change cannot happen without meaningful engagement with staff, communities and politicians. Something the report says has not yet been achieved in Scotland. Honesty about the scale of change needed is indeed challenging, particularly when it can involve closing hospital services. Lengthy and technical IJB papers have not helped to engage members on these boards.

Workforce planning is crucial to the success of care integration. While the National Workforce Plans have now been published, they are still largely at the process stage, particularly in social care. There needs to be a better understanding of future demand, how this is likely to be met and what it will cost. Needless to say, Brexit looms large over this issue. Attempts by some IA leadership teams to promote the privatisation of services has not helped to build confidence. As UNISON surveys have shown, the procurement rules are not being followed properly. If they were, the two-tier workforce provisions (s52) would end this nonsense.

Data sharing and incompatible IT systems are another problem. There are too many local fixes rather than considering a single national solution. Interestingly, the report points to bringing staff together under one roof, rather than solely relying on IT. This is something that the Quality Care Commission recommended in 2015.

Many of the challenges facing care integration in Scotland can be fixed as local best practice shows. There are some national actions that can help, but there is nothing in this report that wasn’t predicted or points to unresolvable structural failure. The underlying problem is austerity - making big service change is doubly difficult when the budget simply isn’t keeping up with increased demand.

Care integration - lessons from Wales

Delivering better health and care integration is a challenge in all parts of the U.K. and internationally. We should try and learn from experiences elsewhere, and I was in Cardiff today contributing to the Cymru/Wales UNISON seminar on the issue.

Wales faces similar challenges to Scotland - austerity and Brexit. The Welsh health minister told the conference that reform should be about better ways of delivering services, not just about saving money. They have had a parliamentary review of care integration that has made recommendations for going forward and a new government plan will be published soon.

The minister was not convinced that big structural change was the way forward, but he was in favour of better partnership working between health and local government. There are good examples of integrated system change locally that can be scaled up nationally. He was strong on the need to engage staff in finding solutions - making it a formal part of the system. As he put it; "Motivated staff are much more likely to do a better job."

Wales has similar problems to Scotland with fragmented domiciliary and residential care, many of which are struggling. The minister said better commissioning and standards had to be part of the solution. He recognised the need to increase funding and they are looking a levy to specifically fund the increasing cost. Something that hasn't really been part of the debate in Scotland.

The research report launched at today's conference highlights a very complex picture of care integration in Wales. Words like 'partnership', 'integration' and 'seamless' service are used, and abused, with means often confused with ends. As in Scotland, the driver is collaboration not competition, but that has its challenges around trust and power. Previous reports have been critical of progress and they have similar problems with short term funding initiatives rather than increasing core funding. 

The core of the report is three case studies on integration. 

The Bridgend approach shows real improvements in outcomes like unscheduled care and long term placements. Anticipatory care is key to preventing inappropriate admissions and building trusted relationships between staff.

Monnow Vale in Monmouthshire is a good example of how locality based health and social care hubs can work. Staff are co-located, they talk to each other and staff are empowered to find solutions that work locally. This is an approach that we should do much more of in Scotland as recommended by the Social Care Commission. It resulted in a more welcoming approach for users and greater continuity of care - creating a relationship with the carers. Trade union involvement in designing services and getting pay and conditions right was important in building trust in working together and redesigning home care.

Ynys Mon (Anglesey) case study is an example of enhanced dementia service using a residential home as a base to integrate services with community health staff. It was obvious that staff had a real sense of ownership, being engaged in service design from the outset.

The parliamentary review, independent of government with a cross-party reference group, pulls some of this together. They recognised the case for change is compelling, but it hasn't always compelled action. Amongst ten key recommendations, it makes the case for co-location of staff, a focus on outcomes (what they call the Quadruple Aim) and a recognition that staff are a key element in service delivery. It is not about restructuring, it's about effective implementation of a seamless service across all services.

In my presentation I set out the lessons from Scotland's experience in health and care integration. Many different models have been tried, but it is still work in progress. Demographic change places additional costs on an already underfunded service, particularly in the local government half of the process. In social care we have a hugely fragmented service that makes workforce planning very difficult. And of course there is always Brexit! We do have decent procurement frameworks, including the living wage, but councils put insufficient weighting on workforce matters and do very little monitoring of the quality of service delivery. 

My colleague from London, outlined developments in England. There is very little action on a national basis in England and just a few local initiatives. In essence it's a mess.

Finally, workforce regulation in Wales is following the Scottish model, with the phased regulation of domiciliary care staff. They have similar challenges in terms of recruitment and retention of social care staff.

Scotland is probably a bit ahead of Wales in terms of legislation and structure. However, the challenges are very similar and they do have some impressive examples of best practice, highlighted in the report. On that basis the research report published today is well worth a read. No one has got integration right yet, so we can all learn from experience elsewhere.

Funding, not more quangos will improve care integration

The implementation of health and care integration won’t be achieved on the cheap. While there should be long-term savings and better care from a shift to community services, it will take time to realise that ambition.

The Scottish Parliament’s Health and Sport Committee has been holding an inquiry into the budget for next year. We don’t have much idea how big the pot will be until the UK Autumn Budget and the Scottish Government decides on its own tax policies. However, that still allows some scope for an examination of the principles that underpin the budget.

The Integrated Joint Boards (IJB) are now responsible for some £8.3bn of expenditure – a substantial part of the Scottish budget and supplemented by local taxation. In evidence to the committee the IJB finance officers highlighted that resources are not keeping up with demands. They said:

“There is emerging evidence which indicates that the current level of resources is less than that required to meet current cost and demand pressures. In practical terms this means that the required shift in the balance of care will take longer to achieve. A number of Integration Authorities have modelled the level of additional resources required to meet cost and demand pressures, with estimates between 3% (for 2018/19) and 14% (over two years) of existing budget.”

The clear message to the committee was that increased demand, largely due to demographic change, means that they don’t even receive a standstill budget. Transformational change comes with a much bigger price tag.

Measures to reduce unplanned admissions to hospitals and cut delayed discharges can be successful. A number of IJB performance reports demonstrate progress. Not least in Glasgow, which claims continuing decreases in delayed discharges with acute bed days lost falling from 38,152 (13/14) to 15,557 (16/17). However, the picture continues to vary across the country. As I said while giving oral evidence to the committee; unplanned admissions will continue until a full social care service is in place – hospitals don’t turn patients away.

I did notice a definite pitch from IJB directors and finance leads for direct funding and greater control. We should remember that IJBs don’t employ staff and get their budgets from health boards and councils. Their complaint is that funding ‘doesn’t lose its identity’ in this system and they have matrix performance monitoring. Concerns over double counting of health and care funding are valid, as are the constraints of ring-fencing.

It was entirely predictable when you create a system that co-ordinates services that sooner or later the leaders want to create an empire that they have more control over. This leads to a demand for stand-alone bodies – in effect a whole new set of local quangos. 

This demand should be resisted. The change that is required in care cannot be achieved by IJBs in isolation. One of the points I picked up from trade union colleagues in Norway was that separating the management of acute and community services made it that much more difficult to achieve resource transfers. The same applies to councils, who run range of other services that impact on health; like housing, planning, libraries and leisure services. You don’t join up services by fragmenting them even more.

From a staff perspective, such direct control would involve a massive transfer of health and care workers to new organisations. A move that will be resisted by all the trade unions for good reason. Such a transfer would take many years and the harmonisation negotiations would be a complete nightmare. It would require a massive funding pot and divert staff and management effort for years.

It is clear that transformational change in the health and care system requires a significant increase in funding. While there are still some organisational and cultural barriers to integration, more local quangos are not the solution.

Action to recruit and retain health and care staff

The health and care sector in Scotland is facing significant recruitment and retention problems at a time when we need to expand the workforce. We need to take action now.

Today, I was giving evidence to the Scottish Parliament Health Committee's inquiry into workforce recruitment and retention. It's a timely look at the issue given the problems the sector faces and the need to recruit thousands of extra staff to cope with growing demand. And that's before the uncertainties of Brexit, which understandably concerned MSPs as well.

We should start with the data. For the NHS we have pretty good workforce statistics because NHS Scotland uses a common payroll system and therefore ISD can publish a decent analysis of trends. For example, we know that nursing vacancy rates have been growing and currently stand at 2566 WTE. There are similar proportional problems with doctors and allied health professions, including Occupational Therapists.

The same is not true for the social care sector. This largely privatised sector is hugely fragmented and data is heavily reliant on registration with the SSSC. The problem with this is that not all staff are yet registered and some important groups, like PA's and childminders, don't have to register. The interaction with volunteers is another complication. We are therefore reliant on partial employer data and our surveys to plug the gap. We do know that many employers are holding high numbers of vacancies and have turnover rates that would make the worst outbound call centres blush.

This is also an ageing workforce. In social care the median age in all sectors is in the mid to late forties and younger staff are much more likely to be looking to get out of the sector. There is also gender segregation with men making up only 15% of the workforce. One of the barriers in attracting young men into the sector is the prevalence of part-time working. The data actually understates the problem because the SSSC defines full-time as more than 30 hours per week.

In preparation for today's session, I went back and looked at our member surveys in the last 18 months or so. What struck me was the similarity in the concerns of members from low paid home care workers, to professional posts such as district nurses and health visitors. They all point out that these are tough jobs, physically and emotionally, that are getting more complex. The job satisfaction that used to be a feature of the job has been undermined by cuts that leave them with not enough time to care. They also point to limited training and the loss of admin staff support and poor IT systems.

Pay and conditions are a big issue, particularly in the social care sector. In Living Wage Week we should be redoubling our efforts to ensure that care workers are getting at least that rate. We also need to tackle poor working practices such as insecure work, zero/nominal hours contracts and the treatment of travel time. As many staff have said to us, why should we work in such a tough job, with registration standards, when we can earn more stacking shelves.

Finally, let's look at some solutions.

- We must start by valuing the care workforce. Paying them properly with fair work principles being delivered through procurement and sectoral bargaining. That will also help to address gender segregation.

- Workforce planning is more of an art form than a science, but we could do better. Not least by widening the scope from the narrow group of professions currently included. We also need to recognise the scope for expanded roles and initiatives like UNISON Scotland's Skill Charter could contribute to this. 

- Cutting admin support is a false economy, leaving front line staff to perform these functions, usually not as competently. Investment in IT systems and equipment that actually works would also help.

- Structurally, in social care at least, fragmentation of providers has to be addressed. Does a country the size of Scotland really need a thousand adult care providers? 

With a growing demand for health and care workers we need to take action now if the workforce is going to be there when demographic change impacts on many more people living in Scotland. We can make some structural changes and coordinate workforce planning. However, none of that will work unless we value the workforce.

Valuing the workforce is the key to better social care

The key to delivering high quality social care in Scotland is a fairly paid, well-trained workforce that is given the time to care properly.

Today, I was giving evidence to the Scottish Parliament Health Committee on the social care workforce. The committee has been looking at how the new Integrated Joint Boards have been coping with the challenges facing them. Unsurprisingly, new structures take time to settle down and even agreeing budgets has been problematic. 

The NHS needs better social care to tackle delayed discharges from hospital beds. Delayed discharge patients occupied a staggering 567,853 bed days last year, that’s one in twelve beds in NHS Scotland, costing around £114m. These figures mask a human tragedy for many elderly people who want to be in their own home, or even a residential setting, rather than in a hospital bed.

The Health Committee’s survey showed that just four of the 31 Integrated Joint Boards have adequate numbers of care staff to get these patients out of hospital. That reflects our own experience; with social workers reporting that it is becoming increasingly difficult to get providers to staff care packages. One senior social worker told me last week that she rang five providers and none could provide staff for an elderly person due to be discharged from hospital on the following Monday. She had to go on bended knee to the much-reduced in-house team to get a temporary solution. 

We are seeing some very high staff turnover rates from even the better providers. This matters because it is expensive to keep recruiting and training new staff. Elderly persons want continuity of care - seeing a different carer each week is very poor practice.

The quality of care is starkly reflected in UNISON Scotland’s latest survey of home care staff, ‘We Care, Do You?’ Workers describe some pretty appalling practices that none of us would want for their elderly relatives.

So what’s the solution? In fairness to the Scottish Government they have at last recognised that we have to resource social care properly. Years of council cuts have led to a race to the bottom in pay and conditions for these workers and short cuts in care delivery. Even inadequate 15-minute care visits become 10 minutes because they often don’t take account of travelling time.

Just increasing capacity isn’t enough either. If providers can’t recruit and retain staff, the new care packages will only exist on paper and patients remain in hospital.

£250m was allocated this year to improve social care, although it was routed through the NHS, when it is councils that deliver social care. This may make NHS funding look more impressive cosmetically, but it contributes to ‘the guddle’ as I described it in the Sunday Herald.

There was never any transparency over the constituent elements of this money and in particular how much was allocated to ensure the Scottish Living Wage is paid to care workers from 1 October – an essential element of the policy. Just a few weeks before the policy is supposed to be implemented, councils and providers are struggling to get the procurement policies in place. Providers say there isn’t enough money; councils say that’s all they have received. 

We are also concerned that some providers may well pay the correct wage, but will cut back on other terms and conditions. This is contrary to the statutory procurement guidance that refers to all workforce matters – not just pay.

Much of this could be avoided if we adopted a structured national approach to the provision of social care. We should not lose sight of the fact that we will need some 65,000 extra care staff in Scotland by 2020 – so we need to get this right now.

Here is a plan:

- A national sectoral bargaining structure with all the stakeholders; government, employers and trade unions, around the same table.

- This forum to agree a national hourly rate for home care, similar to that agreed for the residential sector.

- Government to commit to early engagement each year with transparent resource allocation.

- A commitment to deliver all the elements of UNISON’s Ethical Care Charter, including the Scottish Living Wage, proper training, an end to insecure work and time to care.

In effect this would be a national framework that would allow the Integrated Joint Boards to get on with the task of agreeing local delivery solutions. This would be a sensible balance between the national and the local. Is that really too much to ask for those who deserve a decent standard of care? 

Home care workers say - We care, do you?

Scotland needs a quality home care service to meet the growing demand and also ensures that patients who shouldn’t be in hospital are cared for at home. While there is a welcome commitment to address this, the service at present is struggling.


I recently outlined the reasons our social care system is in crisis in an article in The Scotsman. Essentially, we have growing demand being met by a fragmented, largely outsourced workforce that has been subjected to a race to the bottom with their pay and conditions of work.


This is reinforced in a report UNISON Scotland has published today. ‘We care, do you?’ looks at the state of social care in Scotland and asks the staff who deliver the service to describe their experiences. The survey revealed:


• 9 in 10 (88%) said they were limited to specific times for client visits, with many reporting this was too short a period to properly cater to a client’s needs.
• Four in five said they believe the service has been affected by budget cuts or privatisation with carers saying the emphasis was now on “quantity rather than quality”.
• Over a quarter (26%) said they were not paid for their travelling time.
• Two thirds (66.5%) said they did not have anywhere to go between visits to have a meal, hot drink or toilet break.
• Nearly half (43%) said they worked longer than their contracted hours.


The Scottish Government is committed to paying care workers the Scottish Living Wage by 1st October this year. It remains to be seen if that will be delivered, as local authorities and providers struggle with the funding arrangements. It is important that the additional resources are distributed equitably and that the poor employers are not rewarded for past bad behaviour. It is equally important that pay is not increased at the expense of other conditions.


Fair pay and conditions are vital to recruit and retain staff. I have read several internal reports that highlight very high turnover rates amongst even the better contractors. Service users need continuity of service provision and turnover rates above 25% per annum cannot deliver this outcome.


Time to care is another key outcome. In today’s report, workers paint a picture of not having enough time to properly care for the vulnerable people who rely on them. The assertion that 15 minute care visits are only for the most minimal needs was roundly contradicted by carers, with some stating that scheduling did not account for travel time between visits.  As one worker described it:
“Sometimes I have 4 clients with all 15min scheduled time in the space of 1 hour with no travel time to each one.”


The section in today’s report on the times service users are helped out of bed and provided with breakfast makes particularly grim reading. As one worker put it:
“Earliest 7am but can still be doing breakfast at 11am, after giving the client a shower so be nearer 11.30 when they eat.”


Getting fair pay and conditions is the important starting point in resolving the social care crisis. However, it’s not enough on its own. That’s why UNISON Scotland is campaigning for local authorities to sign up to its Ethical Care Charter, which sets minimum standards to protect the dignity and quality of life for people who need home care.


It commits councils to buying home care only from providers who give workers enough time, training and a living wage, so they can provide a better quality care for thousands of service users who rely on it.

Valuing the social care workforce

Social care is delivered by people, informal carers and workers, not robots. This means improving the quality of care in Scotland has to seriously address workforce issues.

I was facilitating a session today at the 'Social Care: An Ambitious Future' conference in Edinburgh. The conference covered a wide range of issues relating to the crisis that is our grossly underfunded social care system in Scotland. My session was on workforce issues

Let's start by understanding the workforce. 189,670 people are employed in the social care sector, which accounts for approximately 7.4% of Scottish employment. The typical weekly hours worked by staff is close to full-time at 32.5, with women accounting for 85% of the workforce. The biggest employer is the private sector with 41% of the workforce. The public sector makes up 31% and the voluntary sector employs 27% of the workforce. This is a growing workforce as demands on the sector grow. However, all providers report increasing difficulties with the recruitment and retention of staff.

Part of the reason for this is the precarious nature of work in the sector. While the workforce is predominantly employed on permanent contracts (79%), there are significant numbers (around 12%) employed on Zero-Hours contracts. This number understates the actual level of precarious work because of the prevalence of Nominal-Hours contracts. These are contracts where staff are contracted to work a set number of hours, but in practice work significantly more.

The biggest immediate problem is pay. The vast majority of care workers are employed in Class 2 (entry level) care worker positions which covers routine care and support work and which typically pays the National Minimum Wage (NMN) (£6.70 over 21) or just above. Shockingly, some providers even attempt to avoid their legal obligations to pay the NMW. For example last week UNISON won a victory over MiHomecare. Staff there were notionally paid the legal minimum, but the company did not pay for the time they spent travelling between clients’ homes — meaning that they received less than the minimum wage.

There have been efforts to establish an industry floor of £7 an hour in Scotland, but this has run into some legal difficulties over State Aid provisions. It has also been overtaken by events with the introduction of the new UK National ‘Living’ Wage set at £7.20 for workers age 25 and over from April 2016.

The Resolution Foundation has highlighted the impact of the new NMN provisions in their report 'Care to Pay'. They calculate that this will directly affect up to 1 million frontline care workers across the UK by 2020 and increasing the annual household incomes of those affected by more than £800. But this comes at a cost – in particular the National 'Living' Wage will increase payroll costs associated with frontline care workers by £23 billion by 2020, on top of £17 billion of costs already implied by the increase in the National Minimum Wage (NMW). There are also additional training, pension and sleepover payments that are not being fully funded, including for those funded through Self Directed Support

There is an agreed ambition from stakeholders to see all employers in the sector become Scottish Living Wage employers – currently £8.25 in Scotland. The latest Scottish Government statutory procurement guidance on workforce matters sets out how this can be achieved legally through procurement. The wide support for this measure recognises that 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.

Of course fair remuneration is only one aspect of fair work. UNISON’s Ethical Care Charter is referenced in recent Commission reports and the Scottish Government’s vision for social work. The Charter covers, training, induction, zero-hour contracts and time to care properly - as well as payment for travel time, travel costs, occupational sick pay and other necessary expenses such as mobile phones.

We published a new briefing on the Ethical Care Charter last week and how all councils in Scotland could implement it. The barriers are no longer legal, they are largely financial. The Scottish Government's draft budget makes some provision for additional funding routed through the NHS budget. However, it remains to be seen how much of this actually reaches social care services given the pressures on NHS provision. Even George Osborne recognised the problem in allowing English councils to raise the Council Tax. There is no such relief in Scotland where the regressive Council Tax freeze drags on, together with further cuts to council budgets.

At today's conference there was a recognition that we need to raise the profile of social care to get the same level of public, and then political, support as the NHS. With a growing elderly population, increasingly socially isolated, there is some enlightened self interested to be tapped into here to build the case for proper funding. Social care is a universal good that we will all need at some stage, part of the fabric of the society we want to see. We also have to debate if there should be at least a national framework, if not a national service, for social care.

Finally, care workers also have strong views about the quality of care. A UNISON survey of Scottish homecare workers exposed the shocking reality of the country’s care services. The majority of workers polled in the survey - Scotland: It’s Time to Care – said that the service is not sufficient to meet the needs of the people they care for, both from the time they can spend and the quality of care they can provide.

Social care plays a vital and growing role in our society. Yet increasing demand, falling real terms funding, and increasingly complex care needs has put the sector under significant strain. At the heart of this cocktail of challenges sits the workforce, which experiences low wages and poor working conditions. Most care workers are highly committed to the work they do, but such conditions are putting them under significant strain. If we want a social care system that can meet the needs of our ageing population and treat recipients in a dignified way, then we need to invest in the workforce that provides it.

 

Time to get serious about social care

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.

 

Creating better jobs starting with those who care for others

If we are to create better jobs in Scotland we need to recognise and take action on job security, worker control, appropriate demand, fair pay and opportunities for training and development.

I was giving evidence yesterday to the Scottish Parliament's Energy and Economy Committee's inquiry into work, wages and wellbeing. The evidence to the committee is well summarised in the Spice briefing.

While the impact of low wages and poor quality jobs on individuals and the economy are becoming better understood, it also has an impact on health. Professor Bambra's evidence to the committee argues that low quality work combines low levels of control with high psychological demand which can lead to increased levels of chronic stress, muscoskeletal conditions, heart disease, hypertension, obesity and mental illness.

There is also a strong economic case for better jobs. Well made by Professor Chris Warhurst at today's committee. The outcome of the current race to the bottom is the precariat. In some countries this can constitute as much of 25% of the workforce, whose contracts are either temporary or informal, or who arrive via employment agencies. In Scotland the numbers on zero hours contracts, particularly in the care sector, are understated because they largely ignore workers on nominal hour contracts.

This approach isn't even efficient. A study by economists at Delft University has concluded that a flexible workforce needs an expanded management bureaucracy to oversee it. Because precarity damages trust, loyalty and commitment, it demands more management and control. An entire generation of free-market workers has begun to act according to the factory adage of the old Soviet Union: “We pretend to work, they pretend to pay us.” The researchers conclude: “Easy hire and fire is at the cost of organisational learning, knowledge accumulation and knowledge sharing, thus damaging innovation and labour productivity growth.”

In its evidence to the Low Pay Commission, UNISON has highlighted that the conditions of the economy meet all the key criteria set out by the Low Pay Commission in its 2014 report as necessary for significantly faster increases in the minimum wage. These include; rising real wages in the economy generally, stable employment and an expectation of sustained economic growth.

Other factors supporting an increase in wages are the upward trend in the scale of low pay in the economy. This will be exacerbated by Government cuts to tax credits and other benefits, particularly for workers with families. The value of the National Minimum Wage has been eroded in comparison to the Living Wage and young workers have been penalised through the lower rates and their exclusion from the new so called National 'Living Wage'. At the other end of the scale there is the growth in the income of high earnings groups that has entrenched the UK’s position as one of the most unequal countries among comparable nations that are members of both the EU and OECD.

The committee asked us for specific evidence on the care sector that constitutes nearly 8% of the Scottish workforce and is a sector largely funded by the Scottish Government. The size of the Scottish care workforce has increased to 199,670, an increase of 5.3%. 77% of these work in home care and 85% are women.

There are some very poor employers in this sector and they have been encouraged by poor procurement practice. The Procurement Act and new statutory guidance should enable us to tackle this by evaluating future bids on their workforce policies including the payment of the living wage. However, the better employers rightly say that this must be funded properly. Given the leverage of government money there is an opportunity to develop the sort of sectoral bargaining that has been so successful in raising standards and productivity in other parts of Europe.

The care sector is a good example of where the race to the bottom in job quality and wages takes us. Staff who are desperate to exit the sector, creating high turnover, losing the continuity of care that is so important.

This inquiry is a welcome look at an important and complex issue and I look forward to their conclusions. However, there are practical actions the Scottish Government could take to develop the ideas in the Working Together report and Fair Work Convention. The care sector would be a good place to start.

 

Can more legislation raise care standards?

Effectively tackling harm, abuse and neglect in health and care settings is vitally important, but is more legislation the best way to address this issue?

I was giving evidence to the Scottish Parliament Health Committee today on the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill. The Bill covers three distinct policy areas: controlling non-medicinal nicotine vapour products (NVPs); tobacco control and smoking on NHS hospital grounds; ill-treatment and wilful neglect; and duty of candour.

UNISON supports the regulation of NVPs on the precautionary principle as we can see the potential risks of these products becoming a gateway to tobacco smoking that has done so much damage to public health. We also support a ban on smoking in hospital grounds.The more controversial proposals relate to legislating for a duty of candour and new criminal offences for ill treatment and wilful neglect.

Care professions generally operate within culture of openness that supports an open discussion of potential harm and the management of risk. It is not clear that a new duty of candour on health and social care services is the best or only way of securing a culture of openness and transparency. It can be argued that consideration should be given to all other avenues for achieving this policy goal. The desired culture change could be secured through guidance, training and improvement support, rather than legislation.

The Bill will certainly create additional costs in excess of the optimistic assumptions in the Bill's financial memorandum. It will increase workload and probably add some bureaucracy that front line staff can do without. IT systems are generally not adequate or joined up to be of much assistance. There will need to be significant training and support.

This legislation could also have unintended consequences. Criminal offences can lead to defensive practice and even a culture of hiding bad practice, rather than the intended transparency. The development of a culture where open and transparent reporting is the norm requires employers to establish clear, no-blame incident reporting systems from which to learn and improve. It is also the case that some definitions in the Bill are less than clear and there is a risk for double or even triple jeopardy, with employment and regulatory procedures.

On the other hand we have to accept that there is inconsistently of approach. Observations made by Healthcare Improvement Scotland has shown that ethical and policy guidance has largely failed on its own to improve rates of disclosure. Research by the Professional Standards Authority outline the impact on health and social care professionals to exposure to stressful situations and heavy workloads, often linked with a requirement to process complicated information and focus on specific goals and targets. This 'stimulus overload‘ is cited as a potential contributor to unreliable implementation of best practice regarding a duty of candour. Normalisation of abnormal events becomes a way of coping with high risk situations.

Legislation can help to change culture although it rarely does so on its own. It will also need leadership, better staffing ratios and proper training and support for staff. All of these are likely to be in short supply with budgets stretched because of austerity. However, the Scottish Government's approach is inconsistent. When we made a similar case for new legislation to protect workers from violence at work, they produced similar arguments against legislation as those who are critical of this Bill. We are at least consistent in recognising the role of legislation!

While the evidence to support legislation in NHS Scotland is thin, it is somewhat stronger in the social care sector. The introduction of commercial contracts has put enormous pressure on staff and managers to cut corners in care. UNISON Scotland's 'It's Time to Care' report highlighted these pressures and they have if anything increased with the introduction of self-directed care. Staff reported that they were not encouraged to report safety or even carer abuse issues, because managers were concerned that they would lose the care package. A recent Employment Tribunal case involving a care manager showed that she was instructed to accept packages even when there were no staff to deliver them.

One reason to welcome the legislation is the emphasis on organisations and not individual practitioners. In remains to be seen how this will work in practice, but it should mean that organisations and their managers recognise their responsibility to provide the necessary support to staff. We have to improve organisational cultures rather than just create a monitoring tool. The remedial and publicity orders in the Bill are useful tools, although we should recognise the internal pressures within commercial organisations to suppress adverse reports.

On balance we believe that legislating for a duty of candour and the new offences could assist in achieving the stated aims. The Bill places important duties on organisations and managers, not just front line staff. However, care services have to be properly funded, otherwise there is a real risk that this Bill will simply result in staff being scapegoated for the system's failings.

 

Giving social care the priority it deserves

The social care crisis in Scotland is not given the priority it deserves, but there is a growing consensus about what needs to be done.

 

I was speaking at the Care Scotland, care at home conference on Friday. The panel was asked to set out what’s wrong with home care and how we would fix it.

 

On a national and local level we need to fix the crazy commissioning system that isn’t working for anyone. It isn’t working for providers who are struggling to maintain a viable business model. It isn’t working for staff; either social workers that are trying to put packages of care together, or home care staff that are the real victims of the race to the bottom in pay and conditions. Most importantly, it isn’t working for service users, who suffer from the high turnover of staff with little continuity of care, or are stuck in a hospital bed because there are no staff to care for them at home.

 

The solution primarily needs proper funding. It’s easy to blame politicians for obsessing about the NHS, but they are often just following public opinion that rarely understands that social and NHS care are interlinked. Personally, I am coming to the view that we need an agreed national rate for home care, as we have for residential care. This would be a rate that is dependent on providers paying the Scottish Living Wage and maintaining a range of other workforce standards. One of the merits of a national rate as against a local top up is that it wouldn’t just reward the bad employers in the sector.

 

That leads me to the second issue, employment standards. Any funding agreement has to include the key elements of UNISON’s Ethical Care Charter. The new procurement guidance rightly recognises that paying the Scottish Living Wage alone is not enough because some providers will simply cut other conditions. There needs to be action on zero and nominal hour contracts, sick pay and travel time. In addition, what comes through strongly in all our surveys is the importance of giving staff time to care and proper training linked to career progression. A recent UNISON survey highlights frighteningly low levels of training. Caring should be a great job and many staff I meet recognise that. But the household bills have to be paid and so many end up stacking shelves in supermarkets instead.

 

I am pleased to say that there was a broad consensus amongst the panel at yesterday’s conference on what needs to be done. Scottish Care also launched their latest research report on this issue, which is well worth a read.

 

The media headline was all about freezing heath spending, but the key finding is that investment in better social care for older people would improve their lives and help to cut emergency hospital admissions. In 2012-13, the average emergency hospital admission for over-65s lasted for 11.8 days, at an average cost of £4,846. That amount could fund either care at home for a week for 27.7 older people or 9.28 weeks in a residential care home for one pensioner.

 

Ranald Mair, chief executive of Scottish Care, said: "If we're going to manage to keep more people out of hospital, to maintain them in their own homes and also to prevent them going into long term care at an early stage, then we actually have to invest in home care. The danger at the moment is that we're continuing to invest in hospitals and as you know, all politicians want to be the defenders of the NHS. This isn't an attack on the NHS, let me be clear. If people need to go to hospital that's where they should be. But what we know is that over 20% of admissions of older people to hospital are 'unnecessary' admissions. They're not going in because of their clinical needs, they're going in because of their circumstances and because of the lack of alternatives."

 

It’s hard to disagree with that. Investment in social care and in particular the staff who deliver care, needs to be one of our highest priorities.

 

Priorities for health and care integration

Given the history of health and care integration, we should be wary of raising expectations over what the new bodies will be able to achieve

All Health Boards and Local Authorities in Scotland are required to submit their Integration Schemes for Ministerial approval by today. The new Health and Social Care Partnerships across Scotland will be up and running by April 1, 2016.

The BBC is running a good feature across the UK today, on how the different administrations are tackling integration. The Scottish Government’s standard response to all questions on bed blocking and social care is that the new joint bodies will sort out all the problems. A response that should send a shudder down the spine of those appointed to lead them!

In my BBC interview I welcomed the broad approach, but urged some caution. Simply moving the managerial deck chairs around will not solve some of the big challenges facing the sector.

There is strong international evidence of what works in care integration and the common feature is that it's about people. Sadly, in this whole process that's the bit that has been given the least attention. The focus has been on structures and budgets rather than workforce issues.

The biggest challenge facing the new organisations is social care. The number of patients in hospital who shouldn’t be, is now the equivalent of the number of beds in Scotland’s newest and biggest hospital - South Glasgow. Setting new targets for delayed discharge is all well and good, but councils need to be funded to deliver the quality and capacity of social care to get these patients into community settings.

Local authorities have taken the brunt of austerity cuts in Scotland while the NHS has had a degree of protection. Demand for social care has also been rising and as a consequence most councils have commissioned a race to the bottom in outsourced home and residential care. Wages and conditions have been cut as well as the time allocated to care properly. UNISON’s Time to Care report and the subsequent survey of staff involved in care integration makes this very clear. We have now reached a position where many providers are unable to recruit and retain the quality or quantity of staff needed to deliver even a basic service.

To address this we urgently need a new procurement framework that addresses how care services are commissioned including a common workforce framework. The workforce element should include the Scottish Living Wage, ending the reliance on nominal and zero-hour contracts, proper training and most importantly, time to care. All of this requires the Scottish Government to resource the changes needed and for the rest of us to give them some political space by recognising that the NHS is only part of the care system in Scotland.

Health and care integration is right in principle, but the practice is more challenging and the first priority is to tackle our crumbling social care services.

 

Focus on social care to end bed blocking

With thousands of beds blocked this winter by patients healthy enough to return home, it's time for politicians to put as much focus on social care as they are on NHS Scotland.

Thanks to data obtained by BBC Scotland we know that over a four-week period, an average of 1,216 beds per day were unavailable to incoming patients in hospitals across the country. NHS England is also struggling with this problem and 139k patients were stuck in beds, unable to leave, in December. Scotland's comparative numbers are more than double, with 31,610 reported in Scotland for a population 10 times less.

Health Secretary Shona Robison said the figures "aren't good enough" but blamed the position the government inherited. Possibly the lamest excuse a minister could give when her party has been in government for nearly 8 years!

Scottish Labour's health spokeswoman Jenny Marra said: "Bed blocking has a real impact on our whole health service and the operation of our hospitals. It is something the government needs to get on top of soon". True, but Labour's policy announcements have been focused on the NHS and not on social care - where the real focus should be at present.

The last edition of Holyrood Magazine has a good analysis on how the NHS in Scotland is being used as an election issue. In fairness to the politicians, they are largely reflecting public perceptions and therefore, as I said in the article, we all need to do more to explain the interaction between health and social care. The ConDem austerity cuts in Scotland are largely being dumped on local government and councils are in no position to respond to the demands placed upon them.

Council social care budgets are to be merged with health budgets. This is aimed at forcing both to work closer together to move patients into the right care setting. The Scottish Government announced £100m in funding which, invested over three years, will be used to help health boards and councils provide support packages for people in their own homes. Welcome though this funding is, it is well short of what is required.

Firstly, we need to fund an increase in capacity. We know from our surveys of the staff involved that assessments are not being delivered in full. That's in addition to patients blocking beds - now the equivalent of the bed capacity in the new Southern General Hospital.

Secondly, it's about recruitment and retention of quality staff. We have a hopelessly fragmented delivery of home care that has been increasingly privatised. Many of the new providers cannot deliver the service because of high staff turnover and recruitment problems. There has been a race to the bottom in pay and conditions, and staff are voting with their feet.

For example, an authoritative new report from the Resolution Foundation revealed that at least 160,000 care workers were being collectively cheated out of £130m a year by virtue of being paid below the National Minimum Wage. How can we claim to be a civilised society when we allow the people entrusted to care for our elderly and disabled people to be treated so outrageously? The Save Care Now web site has a petition on this issue that I would urge everyone to sign.

In Scotland, this is reflected in UNISON Scotland's Time to Care report that highlighted some appalling working practices. The growth in zero and nominal hour contracts is another abuse that needs to end because it directly impacts on the quality of care. Workers on these contracts are simply unwilling to report even care abuse, because of the threat to their precarious jobs.

Under the provisions of s52 of the Local Government in Scotland Act, councils should not be using procurement to create a two tier workforce, but they are. The recent local government benchmarking report says that the 8% shift to outsourced providers has, "contributed to reduced costs through lower salary and pension costs". Progress on extending the living wage through procurement has also been painfully slow.

Getting patients out of hospital is essential for the NHS and the quality of life for people stuck in an inappropriate care setting. It requires greater home care capacity as well as a revitalised workforce using the plan in UNISON's Ethical Care Charter. That is where political parties ought to be focusing their attention.

Big challenges for care integration

Health and care workers support integration, but fear it won’t deliver due to lack of resources

That’s the main message from a UNISON Scotland survey of workers in health and social care who will have to deliver the planned integration of health and care services in Scotland. The report shows that while many staff believe care integration provides an opportunity to improve services, but the impact of budget cuts mean services will get worse

Only 6% of workers involved expect conditions to improve in the next year. 68% believe the situation will get worse. 63% felt that their professionalism is or has been compromised by budget and resource limitations.

The report also includes many verbatim quotes from the workers in the front line. These paint a picture of services which are struggling to deliver.

"Clients are being restricted in activities because of funding as many other services are being withdrawn and a lot have been closed due to local government funding cut backs. This has an effect on family carers a lot of whom are elderly and can receive no respite from their home caring role.'

Staff are generally supportive of integration as an idea and can see advantages in closer working, but fear that a top down managerial model of change will make improvements more difficult

"I’m positive about working with practitioners, negative about being subject to another layer of managerial agendas."

The report builds on UNISON Scotland’s ‘It's Time to Care’ report which also outlined how tight resources are in Scotland’s residential and home care services.

A further indication of the pressures on staff comes in the latest SSSC workforce data. One in thirteen people in paid employment in Scotland now work in social work. However, the size of the workforce appears to have fallen for the third year in a row, from 192,360 in 2012, a drop of 1.4%, to 189,670 in 2013.

The private sector continues to increase its share of the labour market, employing 41% of people working in social services in Scotland. The public sector employs 32% and the voluntary sector employs 27%. This chart gives a breakdown by local authority area:

The largest types of social services are housing support/care at home, care homes for adults and day care of children; together, these account for almost 76% of the workforce. Housing support/care at home services saw the largest drop in the actual number of staff employed, from 64,290 to 61,350.

Around 79% of the workforce is employed on permanent contracts, which is the same as in 2013. Most are also full-time positions, though at least 10% of the employment appears to be on zero hours contracts or equivalent. As we know from the ‘Time to Care’ report this can have serious consequences for care standards.

I’ll leave the last word to the staff who deliver care.

"Lack of local authority care is resulting in delayed discharges within hospital wards which is placing greater strain on the NHS system. Sometimes packages of care are agreed and discharge is arranged but then there is physically not anyone to actually deliver the care"

 

 

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Big challenges remain in delivering care integration

Delivering health and care integration is proving every bit as a complex as we anticipated.

I was at a seminar in Ayrshire today that brought together our council, health and community sector activists to discuss the implementation of the health and care integration plans in the Public Bodies (Joint Bodies) Act. Ayrshire has three Shadow Integration Boards but are planning to adopt a pragmatic local approach by sharing lead roles and manage some services on a pan-Ayrshire basis. None the less it will be a complex matrix structure, on top of what is already a complex array of services.

More clarity is needed on how the new organisations work with NHS, councils and partners in the third sector. Wherever you draw boundaries there will always be a need to work in a connected way with other services outwith the new structures. Front line social workers in Ayrshire very clearly highlighted the problems the private sector in particular is having in delivering the home care hours they have been contracted to deliver.

In my overview, I drew attention to international evidence of what works in care integration. It's a long list on the slide, but the common feature is that it's about people. Sadly, in this whole process that's the bit that has been given the least attention. Most workforce issues have not been resolved, like different procedures; disciplinary, grievance etc. Different salaries and conditions also apply for workers doing similar jobs. There is a national group working on these issues but it is making very slow progress.

There are also different industrial relations models and cultures. However, the positive news is that there is a willingness to adopt a positive best practice and employee reps on the integration boards will help that.

There is a risk that as we focus on the mechanisms of integration boards, we lose focus on the wider changes that are impacting on this sector. Issues like self directed support and budget cuts are happening at the same time. There are also different views on the role of third and private sector in service delivery and different approaches between councils in Ayrshire. Some understand ethical care issues better than others and procurement strategy is an important issue for everyone involved.

There is also demographic change with growing numbers of older people. How this is addressed is not consistent across Scotland. The common picture is the reduction in residential care beds and increasing demand for more intensive home care. However, there are very different patterns of unscheduled admissions to hospitals, and delayed discharges. That is a big cost that was always intended to fund social care. I remain sceptical that much of this revenue cost will actually be released.

Integrating and connecting services remains a desirable objective. However, the challenges colleagues flagged up in Ayrshire today are reflected across Scotland. Structures are of course important, but it's people that deliver quality care services.

 

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Personal care costs escalate

A story in today's Herald newspaper highlights the latest Scottish Government statistics on free personal and nursing care for elderly people living at home in Scotland. Spending has increased by more than 160% since the policy was introduced, with the bill reaching almost £350m in 2012-13.

In 2012-13, 47,680 people benefited from the policy, receiving an average of 8.4 hours of care a week, compared to 32,870 people receiving an average of 6.9 hours of care a week in 2003-04. A further 30,000 people in Care Homes also benefit from the policy.

This large increase in people receiving services in their own homes reflects an increasing older population and a move away from long-term care in hospital and care homes, towards providing care in a person’s own home for as long as possible.

The Scottish Government gave councils the extra £40m, but the latest statistics shows the total bill for free personal care, including packages provided to care home residents, is now £465m. That is another £41m increase since 2009-10.

Cllr Peter Johnston COSLA's health and social work spokesperson said: "... it is evident from the Scottish Government's publication that the policy is becoming more expensive. Councils' social work budgets are under huge pressure, with some - from what we are hearing - nearly at breaking point. It is for this reason that a fundamental debate about the funding of care and support is required."

This view is reflected in UNISON Scotland's 'Time to Care' report. Front line staff describe how the financial shortfall is driving a race to the bottom in social care provision. In addition, the pressure on care homes is reflected in home closures and adverse inspections. This is driving bed blocking in hospitals. There are 837 patients assessed as ready to be discharged in Scottish hospitals - that's the equivalent of the total number of beds in the Southern General Hospital.

More elderly people being cared for in their own homes is of course a good thing. But the policy has to be properly funded. Devolving attendance allowance, as recommended by the Scottish Labour Devolution Commission is a positive medium term solution. It is often forgotten that Attendance Allowance is not paid to Scottish residents in care homes. This means that nursing and personal care support in England is £188 and in Scotland £241 - not quite as significant as it is often portrayed. Free care in Scotland is not quite what it seems given hotel costs and Scotland should not have ignored the Dilnott report.

These latest statistics should be a wake up call and the Scottish Parliament needs to review the funding of the policy now. Before care for Scotland's elderly, gets even worse.

 

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Health and care integration - Scotland and the UK

Health and care integration is right in principle but it will take more than moving the managerial deck chairs around to deliver quality care.

I took a day away from the STUC in Dundee to make a day trip to Brighton to speak in panel discussion on health and care integration at the UNISON UK health conference. I was giving the Scottish perspective on what is a similar challenge across the UK.

The context for integration is pretty similar across the UK. Demographic change is even more acute in Scotland with 25% of the population over 65 by 2035 and an 80% increase in the over 80s. Today's FT had an interesting UK Statistic reporting that centenarians will grow from 14,000 in 2013 to 111,000 in 2037. It will at least keep the Queen busy. Their overall message was let's embrace longevity, it's a good thing. That said, we can't ignore the financial pressures that have resulted, in social care at least, in a race to the bottom as UNISON Scotland's Time to Care report highlights.

There have been efforts to promote care integration since the 'joint finance' initiative in the 1970s, with admittedly limited success. An Audit Scotland report found few examples of effective joint planning. The long waits for patient discharge have largely gone, but 837 patients are still in Scottish hospitals who should not be. That's the equivalent of the Southern General Hospital. The Scottish public service model, based on collaboration not marketisation, should enable joint working, but as the Christie Commission found this hasn't always been achieved.

The new integration model is outlined in the Public Bodies (Joint Working) Act, to be implemented in April next year. This permits two broad models. Lead agency and body corporate bring in councils and health boards together in Health & Social Care Partnerships. Everywhere other than Highland are likely to go for the body corporate model. They will be run by an Integration Joint Board with at least 3 council and 3 Health board members plus non-voting members from the voluntary sector, trade unions and patient groups. Each Board has to develop integration plan (services, budgets) and a three year Strategic Plan. There will also be Locality Planning Groups below council level. All of these plans have to approved by minister who has extensive powers and will set national outcomes and lead an accountability process. No staff will transfer to the new bodies, they will remain employed by councils and health boards.

UNISON Scotland welcomes the less prescriptive model than first envisaged, but remains concerned about the extensive ministerial powers that could be another force for centralisation. International studies show that local implementation is the key to successful integration. The staffing provisions are minimal, but after our Bill lobby a partnership group has been established to address workforce issues. 

Outsourcing remains a concern as home care is the most outsourced public service Scotland and we don't want to see that extended any further - certainly not into NHS provision. The financial provisions in the Act are weak with little indication of how growing care needs are to be funded. The savings identified in the Christie report on unplanned admissions have already been absorbed into rising, not reducing NHS bed requirements. I would also argue that GPs are weakly integrated into new system and they can be a big driver for admissions to hospital.

Finally, for the future more work is needed on the detailed secondary legislation and local plans. UNISON's  short term focus is on effective joint branch working and developing skills. The industrial relations cultures in health and local government are also very different. 

In the longer term, I argued that we need to address three key care issues. Improve the social care workforce as set out in UNISON's Ethical Care Charter. Find a way of funding care at the level we are going to need. And develop a new social contract that sets out the responsibilities of the state and the citizen. Vague concepts like co-production and asset based approaches need more definition.

This was a very interesting debate, even if I struggle with the bewildering acronyms the English NHS has imposed on itself with multiple types of care integration and privatisation. As always when I hear about NHS England, I am grateful for devolution and the decisions a Scottish Labour government took to dismantle marketisation. 

Mick Jagger should make us think about ageing population

We are told this week that Mick Jagger is delighted with the prospect of becoming a great-grandfather, according to his granddaughter Assisi who is expecting her first child in April. I highlight this news story in contrast to the regular media stories that forecast doom and gloom over our ageing population.

There is no doubt that demographic change will bring many policy challenges and I participated in a round table discussion hosted by The Herald on this very issue yesterday. However, the phrase 'demographic time bomb' ignores many of the benefits to individuals and communities. Older people remain significant economic contributors as well as important carers, of young and old, in their own right. Many of the voluntary organisations that make up the fabric of our society would collapse without the support of older people.

There is also some recent academic work that argues that we may be exaggerating the impact on health services because we are likely to be healthier into old age. 60 is the new 50, as Mick Jagger might illustrate. There is also a lot a focus on nursing home costs, but this only applies to a tiny proportion of older people.

Of course, none of this means that we shouldn't address the policy implications of an ageing population. The additional public spending impact is estimated at £2.5bn in Scotland by 2030. When I was working with the Christie Commission we were told that £1.5bn might be released from unplanned hospital admissions to help pay for this. With the increasing demand for beds that is now looking a remote prospect and I don't see any replacement plan in the current care integration proposals.

One aspect we do need to focus on is the workforce that cares for older people. We are seeing a race to the bottom in terms of pay and training, with care being viewed as the new retail in job terms. I was discussing this with a group of home care staff recently. Most of the younger staff told me that they would leave as soon as they could get a better job - little prospect of the essential continuity of care that many older people need. Others described minimal training before being expected to address complex care needs. Even more worrying, those on zero or nominal hour contracts said they wouldn't flag up safety or abuse issues for fear of losing hours.

Demographic change has positive implications for our society and we shouldn't over emphasise the negatives. What we should do is start serious planning. Respecting and developing the workforce is a good place to start.

Will care integration Bill make a difference?

I was giving evidence at the Scottish Parliament's Health Committee today on the Public Bodies (Joint Working) Bill that aims to improve health and care integration. I covered three broad areas of the Bill.

Firstly, the governance arrangements in the corporate body option are confused, particularly for staffing issues. As staff won't, in the main, be employed by the new organisations, it is unclear how major staffing decisions will be addressed. There are statutory and non-statutory procedures that need to be accommodated. This reminds me of the similar shambles in the recent Police Bill!

Ministers have many powers of direction in the Bill and there is a legitimate concern that these will be used to impose a top down model of care integration. All the international studies show that this won't work.

Secondly, the financial provisions are inadequate for the scale of the challenge ahead. The big goal of integration is to release cash from avoidable admissions to hospital, estimated at £1.5bn. I have always been sceptical about this figure, but now that health boards are demanding extra beds to cope with demand, supported by the Health Secretary, it is difficult to see where the extra funding is coming from.

The key issue is how we fund social care. It is a national disgrace at present with a race to the bottom in quality and quantity. The service is increasingly being delivered by staff, barely above the minimum wage, on zero or nominal hour contracts. As one care worker put it to me recently, the shocking 15 minute visit is becoming the best that elderly people can expect.

Thirdly, the Bill largely ignores staffing issues, a point I have covered in previous posts. Care is delivered by people not robots, but reading the Bill you wouldn't recognise that fact. There appears to be more concern about who sits on boards than the quality of care.

The Committee Convenor reasonably posed the question, will this Bill make any difference? Sadly, I remain sceptical that it will. The success of care integration requires local design and a number of people actions, none of which are addressed in the Bill so far.