Submissions from Social Work Scotland to Derek Feeley, Chair of the Independent Review of Adult Social Care
Social Work Scotland is the professional body for social work leaders, working closely with our partners to share policy and practice, and improve the quality and experience of social services. We are a key partner in the national Adult Social Care Reform Programme, creating an operational framework for Self-directed Support across Scotland, which through the practice of relationship-based social work, supports the consistent delivery of social care that is personalised, rights-based and which supports active citizenship. Another of our current projects is aligned to a Scottish Government programme (Health and Justice Collaboration Board) to test and implement frameworks for the delivery of integrated adult social services in Scottish prisons.
We welcome the focus of the Independent Review of Adult Social Care on sustainable improvement to adult social care in Scotland within a human-right frame of reference, and we have been delighted to welcome Derek Feeley, chair of the Review in meeting with Chief Social Work Officers and members of the Social Work Scotland Adult Social Care Committee. At that meeting, Social Work Scotland presented Mr Feeley with a summary report of key messages for the Review from social work leaders. Our formal submissions to the Review expand on those key messages, and we look forward to ongoing engagement with the Review.
Social Work Scotland’s response comprises:
- The main submission – read the full text below or download a copy of this document (PDF)
- A supplementary submission provides a brief analysis of the impact of demographic change on the need to spend on adult social care in Scotland. In particular, it reviews the most recent work by the Scottish Government on this issue, in the Health and Social Care Medium Term Financial Framework (HSCMTFF) published in October 2018, and also used subsequently in the Scottish Government’s Integrated Health and Social Care Workforce Plan for Scotland published in December 2019. Read the full analysis here. (PDF)
- A further supplement, which looks at adult social care expenditure in the decade of austerity – comparing Scotland with the rest of the United Kingdom. Specifically, this document underpins the others by analysing the most recent local authority expenditure data for Adult Social Care in Scotland, from the published financial returns; and looks at whether Scottish social care expenditure has fared better or worse than in England or in Wales over the period of austerity, using available data from the Public Expenditure Statistical Analyses (PESA) for “personal social services” published annually by HM Treasury. The financial data is augmented where relevant by available service and activity statistics to help paint a fuller picture. Read the full analysis here. (PDF)
Summary of Social Work Scotland’s main submission
The Independent Review of Adult Social Care[1] is an important opportunity for Social Work Scotland to articulate positions in respect of the scope, nature, delivery, management, governance, regulation, funding and future direction of adult social care in Scotland. Within this, engagement with the Review (both written and in-person) provides a chance to emphasise the unique role and contribution of social work, as a distinct but a core component of social care.
Social Work Scotland have responded to previous inquiries and consultations looking at similar questions (See Appendix A). Building on these responses, and following structured discussions within (a) Chief Social Work Officer and Adult Social Care Standing Committees and (b) members of the Board and partners (including Chief Officers and COSLA), Social Work Scotland has identified a number of key messages/positions to be fed into the Review. The effort has been made to ensure these messages/positions are consistent with a vision for adult social care that is ambitious but deliverable. The key points are:
- Choice, control and personalisation should be the foundations of our social care systems, enabling an asset-based approach to assessment and support, rather than a medicalised model based on deficits and eligibility criteria. However, it is the availability and flexibility of resources in the system (money fundamentally, but principally people) that significantly determines the degree to which an individual or family experience the system as positive and enabling, or detached, bureaucratic and impersonal. The need to manage insufficient and finite budgets requires local authorities and Health and Social Care Partnerships to impose eligibility criteria that render the concepts of choice and control meaningless to a great extent.
- Only the person living their experience, and those who are close to them, can speak to that experience, describing the good and bad, their hopes and concerns. The design of social care, from the level of an individual plan to the nation-wide system itself, must be led by people’s own experience and insight. Commitment to such an approach demands more, however than providing opportunities for people to speak. Those listening must be motivated and equipped to understand what is being said and take appropriate individualised or systemic action in response.
- An effective social care system enables people to build on their own strengths, with support from others where necessary, to achieve positive, personal outcomes. Policies, structures and processes should be designed on the basis of subsidiarity, pushing power down the system, into the hands of those requiring support, and those who support them. Social workers, operating with the necessary skill, autonomy and authority, have an essential role in such a system, surfacing people’s personal choices, and balancing rights and interests with society’s duty to protect people from harm (in its many forms, including financial and emotional).
- Social care – indeed all social services – should not just respect human rights, but proactively work to give human rights meaning and effect. That is only possible when people working in the social care system (and in particular social workers, who have statutory responsibilities to balance rights and risks in complex circumstances) feel empowered and incentivised to act in the defence or promotion of an individual’s human rights.
- People’s circumstances are too unique, and Scotland’s physical and human geography too complex, to guarantee consistency of experience within our social care system. But we can aim to deliver consistency of practice(enabling people to determine what package of support, and level of control, would be best for them) and greater consistency of offer (the support options available to a person) in every community.
- Social Work is a discrete but essential component of the Social Care system. Reform of adult social care, as with reform of children’s social care[2], drug and alcohol services[3], mental health[4] and justice[5], must attend specifically to the unique role and requirements of the social work profession, which holds statutory responsibilities to safeguard, to assess need and to ensure the provision of care and support. In other words, reform must answer the question “what does social work requirements in order to fulfil its statutory and ethical functions?”
- Reform of adult social care must be considered in the context of parallel ‘whole-system-change’ agendas, including the Promise (children’s social care) and justice. Individually, each is a positive opportunity to implement the type of public service reform identified by the Christie Commission. However, they also risk fragmenting the social work profession into separate silos, at a time when the profession’s coherence and interconnections are critical to the realisation of holistic, ecological and person-led support. People do not fall neatly into silos, and social work as a generic profession is uniquely well situated to support an individual and their family and support network to navigate the boundaries of our public services and wider societal inequities.
- Health and Social Care integration has delivered many benefits, and while it does present challenges, we are too early in our national change journey to expect all issues to have been resolved, or to risk unpicking the progress made to date. Reform of adult social care should be focused on addressing the deficiencies of the current governance and delivery structures.
- Social care is just shorthand for a structure within which people work with people. Real change will only come if proper attention is given to people (workforce and leaders) within those structures, utilising what we now know (in particular from research into implementation) about how to shift behaviours, practice and outcomes. A desire to change is not sufficient. Nor is an increase in resources or changes in the law. Systematic work must be undertaken, over a number of years, which enables and supports the frontline workforce to change their approach. At Social Work Scotland we are attempting to incorporate the insights offered by implementation science, and encourage the Review to consider what that body of evidence tells us about effecting sustainable change.
- The national improvement ‘offer’ for social work and social care needs to change. The recent introduction of National Health and Care Outcomes is a welcome development, but an effective national infrastructure is not in place to support sustained improvement across the sector. The conflation of scrutiny and improvement functions within the Care Inspectorate and within the Scottish Social Services Council has impacted these organisations’ efficacy in those capacities. Decisions must be taken about the siting of scrutiny and improvement support functions so that there is maximum benefit for service delivery.
- In attending to the unique role and requirements of social work over the long term, as well as improving consistency of practice, providing subsidiarity within the system, and offsetting the potential fragmentation of the profession, Scotland should establish a national social work agency, differentiated from a national care service. With responsibility for supporting quality and facilitating improvement, it would sit alongside equivalents already in place for education and health. This body would not have responsibility for the regulation of the workforce (which would remain with the Scottish Social Services Council) or delivery of services (which should happen at a local level), but it would lead to learning and development, implementation of new models of practice, attending to issues of professional parity, etc.
- The delivery of social work (safeguarding, assessment, monitoring, support, advice, review) and social care (practical actions to support people meet their personal outcomes) must be local, embedded in and responsive to communities. People’s contexts, needs and environments are varied, and our social care system must reflect that; particularly if our objective is for social care to be personalised, with people having control However, social care could be improved through the establishment of national structures which validate its central role in society, acknowledge the contribution and requirements of those who work within it, and which assist with improvement and implementation (e.g. adoption of new technologies). A National Care Service, under this formulation, would not be involved in the delivery of care, but rather the management of resources within the system.
- Social Work Scotland acknowledges improvements made to the statistical information available about adult social care in Scotland and the ongoing effort to link this data to that available for the NHS so that a more holistic picture can be formed about health and social care as a whole. However, the staff resources needed to support and maintain information systems locally have been severely cut back in recent years. As a result, the national adult social care statistics published in Insights in Social Care: Statistics for Scotland. Support provided or funded by health and social care partnerships in Scotland have many gaps which have to be estimated, where possible, making some of the data difficult to use. Key data time-series, such as on social work assessments, are no longer published, and we are concerned that the social care expenditure information collected by the Scottish Government is being severely cut. We agree with the recent review by the Office of National Statistics that the evidence base for adult social care is under-resourced compared to that for the NHS.
- Above all, there is insufficient funding in the social care system to deliver the improvements the Independent Review seeks in terms of the outcomes achieved by and with people who use services, their carers and families, and the experience of people who work in adult social care. Despite the best efforts of local authorities to protect social care from the effects of funding reductions over the last eight to nine years of austerity, adult social care expenditure has fallen per head in real terms, especially for older people, and the demographic challenges posed by the ageing population have largely not been met.
- We confidently believe the significant additional investment will be needed, in the short, medium and long-term and we urge the Review group to be bold in its recommendations to deliver the investment needed to achieve the national care system its people need and want.
The rationale supporting our key messages / positions
Definitions
A priority in our discussion with the Independent Review is building a common understanding of what is being referred to by the term ‘adult social care’.
We believe a distinction should be drawn between social care[6], a concept that implies the delivery of a service to an individual, and social work[7], whose function is specified under the Social Work (Scotland) Act 1968 as undertaking holistic assessments and determining the level of support required to meet eligible needs. Moreover, social work is a proactive service, rather than simply a reactive one; it exists and is empowered to take action with people made vulnerable by their circumstances, balancing their rights with those of others, and the risks of their actions to themselves, their families and wider society.
The role of social work is therefore dynamic and complex, working alongside people and families at often challenging moment and transitions. In helping to protect people social workers must sometimes use statutory measures, bringing them into conflict with the individual and families. It is a difficult but essential role in a society (and social care system), where not every individual is in a position to determine their best interests alone or the best interests of those they have responsibility for.
The position of social work as a profession within social care
Social work is currently the gateway through which most individuals access social care support funded by the state. In order for that social care provision to be delivered to the right people in the right way, social work practice needs to be independent and robust (i.e. true to its statutory and ethical underpinnings), with the knowledge and expertise to navigate a variety of settings, including home, hospital, residential care homes, homelessness and prison. It needs to be equipped to work with people of any age, in a way that situates the individual within a web of relationships and interactions. Responding to an older person affected by domestic abuse may necessarily involve family, friends and other professionals.
Among the regulated professions, Social Work is uniquely occupying the liminal spaces between universal services – education, health, justice, housing, welfare. Where there is a contraction of universal service provision (usually followed by a heightening of thresholds) or a conflict between a universal service and an individual/family, social work responds, and in our response, we consider the person holistically. We have seen several examples of this in recent years:
- Where affordable and/or appropriate housing is unavailable, social work is tasked to coordinate the necessary support for people to live safely in their own homes.
- Where NHS capacity restricts (leading to longer waiting times or removal of service) social work is responsible for identifying or developing service models which can support people with very complex needs to live in their community.
- Where clinical assessments for autism or other learning disabilities (which can appear very inconsistent between areas) limit the NHS funded options for an individual or family, social work must engage to find alternatives.
- Where pastoral and pupil support posts are lost from schools, social work is challenged to manage the needs of vulnerable children within their families; many of whom will have complex needs of their own.
Due to a number of factors, some going back decades, the role of social work within the social care system has been pushed towards transactional care management and adherence to bureaucratic processes and procedures. In practice, this means that social work acts as both gateway to and gatekeeper of social care. Frontline social work effectively acts as a control for finite local authority budgets, and this causes us a professional dilemma. Resource allocation processes often impact our ability to enhance human rights and the quality of the relationship with families. It is more straightforward to develop a care and support plan for a service or a budget; it is much more time consuming to get alongside the person, consider their life complexities and the potential contribution of their community and natural support to them living a full and rich life, then work collaboratively with them on how to go forward. This approach benefits personal outcomes but comes with a long term financial cost.
Cost-cutting and overreliance on a care management approach have resulted in proportionately fewer qualified social workers available who are able to engage in this way to support the growing population of adults with complex needs. Shifting to a more intense practise model will require additional financial and other resources, but in the end relational, therapeutic support would much better support people’s human rights, and should itself be a right. This is demonstrated where local authorities have shifted towards this approach[8].
Social work’s specific statutory duties centred on the delicate balance of rights and risks – both individual and societal – demands well trained autonomous professionals supported in their duties by their authority’s Chief Social Work Officer.The CSWO remit is wide-ranging with safeguarding responsibility for individuals at risk, for proper deployment and support of the social work and social care workforce, for ensuring robust and effective systems and processes, care governance, and continuous improvement across the whole range of social work and social care services. The CSWO is directly responsible for some statutory functions which restrict personal liberty and has specific duties in relation to safeguarding.
The widening of regulation and inspection into the social care workforce and services has, to an extent, diverted focus from social work as a distinct profession. This becomes problematic when social work enters into partnership arrangements across adults, children and families and justice, where the unique contribution of social work is lost to view. Social workers can become demoralised and disenfranchised as professionals.
Social Work Scotland believes that there is much to be gained by the proper integration of health, social work and social care. However, this needs to be on the basis of a differentiated understanding of the principles and values of all the professions involved, retaining each profession’s unique contribution and impact within local integration arrangements. To facilitate this, we are supportive of measures that would consolidate social work as a genuinely national profession, recognised and supported nationally, underpinned by common terms and conditions and a strategy for its development.
A national profession, perhaps supported by a national agency, would also provide greater opportunities for professionals to progress professionally, without having to take on management responsibilities, and encourage greater professional autonomy in the carrying out of assessment and support planning. In parallel, similar steps for our colleagues in social care roles would potentially give their essential work proper value and status.
Resources and implementation of complex change
The social care model in Scotland was not designed or funded to meet the current expectation of provision or demand. An increase in complexity of people’s circumstances has been well documented, as has the disastrous impact of UK welfare reform on the impoverishment of many people and their families. These factors serve to increase the demand for social work and social care services.
Social Work Scotland members increasingly experience the effect that real-term spending reductions is having on their ability to sustain levels of service, maintain quality and provide non-statutory early help to prevent escalation into crisis. Social services (social work and social care) as a whole system within the integration environment with health must be sufficiently funded to meet its statutory duties and have clear, fair and well-functioning mechanisms for resource allocation within the overall available funding. Despite an overwhelming commitment from social work and social care services, the fragility of the wider social care system has become all the more apparent during the Covid-19 pandemic.
Social Work Scotland believes that the system could be reimagined to be a much more dynamic interplay of social infrastructure supporting citizens’ human rights as individuals and within families and communities, with a combined workforce operating at the community level.
Whilst there is much widespread agreement across national and local, public and independent sector, and national partnership organisations, as to what good social services look like (enshrined in the Social Care (Self-directed Support) (Scotland) Act 2013), the question is what will it take to design and implement the changes necessary to meet these aims for everyone in all areas of Scotland?
It is critical that we come to a collective understanding of the essential elements that contribute to the successful implementation of whole-system change, including the roles and remits of regulatory bodies, improvement agencies, and vehicles of service delivery. This is what has been missing in the implementation of recent ambitious and transformative social policy in Scotland.
Our view has been shaped by our experience progressing implementation of self-directed support in Scotland. Approaching this through the structure and insight offered by implementation science, we have made progress in identifying the essential, non-negotiable components which need to be in place for a publicly funded social care system to enable a person and/or their families to be in control of their life, regardless of their disability (visible or hidden) or life circumstances. Among those core components are established practices, which when reliably delivered by a well-trained and supported workforce, consistently deliver desired results. We also know what infrastructure needs to look like (including upstream community assets, accessible housing, case management IT systems, technology, administrative support, commissioning and procurement, eligibility policy, finance and budgeting systems), and what leadership needs to look like (and have as skills) in what are highly adaptive environments.
Community-based support
Over the past decade, support to build community capacity, in the shape of community learning and development services, community workers, and grants to community groups, has been critically reduced across Scotland.
Investment is required to ensure that communities are ready and resourced to engage in strategic planning and commissioning processes. Independent support organisations, such as those funded by Support in the Right Direction (SMD), are vital in ensuring the voice of people who use services and carers are invited and heard.
Engagement should lie at the heart of decision-making and is the key to people having meaningful choice and control in their own support. Engagement supports the principles of personalisation underpinning Scotland’s Self-directed Support (SDS) legislation. Practically, a good engagement that personalises social care means that care arrangements are more likely to meet needs and less likely to go wrong.
The wide range of asset-based approaches and resources already available are used in a piecemeal way across Scotland but can be abandoned or distorted when budgets are tight. In order to implement these approaches, which often conflict with the traditional ‘way we do things’, attention needs to be given to workforce training and coaching, supportive systems and devolved leadership.
We feel very strongly that there needs to be consideration of the range of people’s lived experiences when designing and constructing social work and social care services. Often the focus of public discussion around social care is older people with personal care needs. Other individual experiences, such as adults with complex learning disabilities or mental health, are not so well profiled, or held in mind. Those experiencing alcohol and drug addiction, domestic abuse and the justice system tend to come from communities experiencing the greatest health and social deprivation. An adult social care system is as much about these experiences as any other; these voices must come to the fore.
Eligibility criteria reform and human rights
Current eligibility criteria are deficit-based assessment of levels of risk to an individual if care is not provided. They run contrary to the principles of personalisation, as they drive time-and-task service provision. They are applied differently across Scotland and result in unnecessary variation in outcomes for individuals. The current approach to eligibility is impacting too severely on vulnerable people and those at the edge of social care, and we strongly recommend that the National Eligibility Criteria be reformed.
Social work and social care financing need to be sufficient to support the quantity and types/models of care necessary to support our population. Services in many areas of Scotland are currently constrained such that they are only able to address critical risks (as defined in the National Eligibility Criteria) by the provision of personal care only, leading vulnerable people to struggle when their needs change or when their needs are social in nature rather than physical. Our work in the implementation framework for SDS shows us that the current national eligibility criteria are not fit for purpose and indeed run counter to the values and principles of Self-directed Support. We recognise that a framework is required to ensure fair distribution of resources which should support strengths-based social work, community social work and ensure early help is provided for people with lower levels of need.
The provision of only critical level services presumes that intervention for anything less can be picked up by family or local community, and that the person has the capacity to organise and manage sometimes complex support arrangements. In some settings (for example prison) people do not have this level of family or community support and are not able to follow signposting to where third sector support might be available. Lack of early help precipitates crises which are costly in outcomes for the person and financially for the local authority.
There should be consideration given also to the variation in charging and contributions policies across local authority areas and their disproportionate impact on individuals with similar needs in different areas of Scotland
While supportive, we recognise the challenge inherent in determining how social care needs (as articulated in social work law) are incorporated into a human-rights-based frame in a meaningful and measurable way. Underpinning principles should cover the range of activities necessary for ‘active citizenship’, including reducing isolation, supporting people to make and maintain friendships, promoting vocational skills, supporting people to develop and enhance life skills, promoting physical and mental well-being, and mitigating health inequalities.
This would involve supporting people with complex needs in personalised ways, supporting carers, promoting SDS and personalisation within partnerships, working with people at the earliest opportunity to maintain, improve or maximise independence, building capacity in the community and with sustainable services, ensuring the best value and effective partnership working, reducing dependence on high-tariff services, and creating services that are aware and confident about using and utilising technology.
This ideal approach will require considerable additional resources, particularly as applied to a growing older population. The population shift will impact disproportionately on women, who provide most of the care to family members. Consideration must also be given to how to properly resource the Carers (Scotland) Act 2016, giving real effect to the principles of that legislation.
Commissioning for personalisation
We note that the majority of pre-Covid local Commissioning Plans are weighted towards health-related matters and make little or no reference to personalised care and support. A perspective that embraces the holistic person with the right to choice and control should be central to framing more personalised commissioning practices.
SDS legislation calls for innovative solutions to allow people to hold individual service funds, necessitating a shift in commissioning practice from block funding to personal commissioning, to enable more freedom of choice and greater control.
We acknowledge that there is some financial risk in departing from traditional service models to new models that might initially be underused. We would support more discussion on how risk might be shared.
Many services commissioned and arranged by the local authority (Option 3) are delivered on the basis of ‘time-and-task’, and this runs counter to a human rights-based approach to delivering care and support because people’s needs and choices naturally change on a day-to-day basis. Introducing more of a personal approach is essential to assist people in receiving support in a way that meets their personal outcomes. We believe that quantifying ‘time’ rather than ‘task’ would allow greater choice and control by individuals, whilst allowing for a budget to be allocated to meet personal outcomes.
Embedding Self-directed Support as good social work and social care
Scotland is a country with significant geographically and economically variation, with diverse and vibrant citizenship with whom we should be aiming to personalise care and support and to offer people choice and control of how they want to manage their lives.
We recommend that the review considers what implementation science might offer in our national attempts to implement SDS consistently across Scotland. We believe that this approach is the most suited to undertake the sort of complex, adaptive change required to meet Scotland’s ambitious progressive policies.
With national partners and local authorities, we are asking what it will take to embed SDS in a sustainable manner across the geographies of Scotland and across all care groups equally. In accordance with best international implementation practice, this includes examining practices and tools for their effectiveness and fidelity, and understanding and promoting the system drivers necessary for adaptive change.
Going forward, we strongly support a shift from the traditional ‘care management’ approach in adult social work to more relationship-based practice with the supported people at the centre of decision making. Systems and processes would need to flow from that guiding principle.
This approach would see LAs/HSCPs move away from care management to a more traditional form of social work, working relationally and enhancing the natural supports of family, friends and neighbour’s contribution through such models as Family Group Decision Making and Community-Led Support. A radical shift of focus of integration authorities to support people to self-manage, on personalising care and support at home and on effective early intervention and prevention would involve working collaboratively with a wider range of partners including education, housing and community representatives using shared decision-making processes and sharing both risk and responsibility.
Whilst housing statements are required to be considered by Integration Authorities, better arrangements are needed to influence housing providers when they’re planning adaptations to the existing housing stock. We would want to see housing developers required to contribute toward the provision of community health and social services. We could require a certain proportion of new-build houses to be ready for use by someone with a high level of support needs.
Technology needs to be at the heart of the future of care preserving independence and supporting social interdependency. It should not substitute for human contact. The National Digital Platform should incorporate as great a focus on technology to deliver social care as on health and should be given the highest priority as a core enabler.
Data and other systems require to be better aligned to the principles of SDS. Much time and effort are spent on managing outdated information systems that do not link well around the person. There is no national requirement to capture outcomes achieved for adults.
Data that is useful to improve frontline operations currently have less priority than aggregated performance management data, which we argue from an implementation perspective is not sufficient as little can be learned from it.
We have also found differences in resource allocation across client groups that do not comply with a rights-based approach. Algorithms underpinning local resource allocation systems favour younger adults over older adults, leading to some outcomes being unfunded or underfunded. In many cases, only critical personal care needs are resourced.
Workforce
A key driver of any adaptive system change is workforce; selection, training and coaching. In order to attract a competent and committed workforce, remuneration should reflect the complexity and responsibility of roles across a varied employment landscape. Innovation is required in how we support people to employ their own personal assistants (employed with an Option 1 Direct Payment). We need an inward migration system that can attract skilled workers into social work and social care. We need to focus on attracting workers to urban, rural and island areas and keeping them engaged and motivated. We require a gendered analysis of the workforce if we are to understand how to attract men into the social work and social care workforce and how to best support women in the workforce.
With budget cuts over the past decade, local authority social work learning and development teams have all but disappeared, impacting greatly on the ongoing training of social work and social care staff. This highlights the lack of parity of social work and social care with other professions such as teaching and nursing. If adaptive change is to be implemented effectively, then the workforce requires not only high standard skill-based training but ongoing intensive coaching and supervision, and to expect pay rises in line with those offered to nurses and teachers.
National Care Service
While we believe that social work and social care needs to be delivered locally, Social Work Scotland is supportive of the development of a national adults practice model (similar to GIRFEC) which support consistency of approach across Scotland whilst allowing for variation only where this is reasonable in the context of local geography, demography and cost of living.
However, we are unclear how the principles of choice and control central to Self-directed Support can be realised by the creation of a National Care Service if it is to be responsible for the delivery of social care. It may be that a National Care Service can have the most effect as a layer between the national government and local delivery, driving greater consistency, improvement in the workforce, equitable distribution of resources, etc.
While the concept of a National Care Service may be attractive in some regard (e.g. a driver for consistency), we have a practical concern about the design of such a service and how it might be implemented as intended within Scotland’s governance landscape.
