Health and Sport Committee
Meeting date: Tuesday, September 27, 2016
Official Report 548KB pdf
Agenda: General Practitioner Recruitment, General Practitioners and GP Hubs, Social and Community Care Workforce
- General Practitioner Recruitment
- General Practitioners and GP Hubs
- Social and Community Care Workforce
Social and Community Care Workforce
The third item on the agenda is an evidence session on the social and community care workforce. We welcome Shona Robison, Cabinet Secretary for Health and Sport, and, from the Scottish Government, Geoff Huggins, director of health and social care integration; Alan Baird, chief social work adviser; and Sarah Gledhill, sponsor team lead for the Scottish Social Services Council.
I invite the cabinet secretary to make an opening statement.
Thank you for the invitation. I hope that committee members will recognise the importance of the Government’s commitment to integrating health and social care to ensure that people have access to the right care, in the right place and at the right time.
As people in Scotland live longer, often with complex support needs, we must work innovatively and collaboratively with colleagues across health and social care, and with communities themselves, to ensure that services support people, as far as possible, to stay in their own homes and communities for as long as possible. We know that that is generally what is best for people’s wellbeing, and that it is what people want.
Our new health and social care partnerships all became operational on 1 April this year; they have the real power to drive change. Having the ability to plan, design and commission services in an integrated way from a single budget enables them to take a more joined-up approach, to shift resources more easily to target preventative activity and to take more holistic approaches to care and support, which will improve the experience and outcomes for all the people who use the services or need support.
We spend nearly £4 billion each year on social care support, and it is vital that we use that resource in the most effective way to deliver the best outcomes for the people of Scotland. Health and social care integration provides us with the opportunity to do that and to be more creative and innovative in the way that we deliver care.
We know that investing resources in community services rather than acute settings and improving links between care in hospitals and care in communities improves outcomes. I recently announced our plans for East Lothian community hospital, which is a good example of how the different care sectors can work together to ensure that care is joined up and delivered closer to home and family with facilities for day care services. We have already signalled our commitment to resourcing care in community settings by allocating a further £250 million from the NHS to health and social care partnerships to protect and expand social care services and deliver our shared priorities. That includes our commitment to enable the living wage to be paid to care workers who support adults from 1 October.
Services need to be fully flexible to meet a person’s needs and empower them to co-produce and self-direct their support to make choices about how their care can best be delivered. That shift requires fundamental change across the whole system and culture, from decision makers to the front-line staff who provide care and support on a daily basis.
To achieve a transformational change, it is vital that staff are fully supported. Our statutory outcomes for health and wellbeing, which underpin integration, address the importance of staff engagement and support. Partnerships are required to publish annual performance reports that set out their progress in relation to the outcomes. As you have heard from others, the landscape for the social and community care workforce is complex, and we all recognise that we must work across all partners and stakeholders to ensure that we have enough people with the right skills to support the needs of people with a variety of needs in communities.
We are committed to ensuring that the entire workforce is fully supported. That is why, in addition to the investment that I mentioned earlier, we remain committed to the policy on upskilling the workforce. That policy is wider in scope than any similar policy elsewhere in the UK. When the policy was introduced, around 80 per cent of the workforce did not have any qualifications. Now, through the work of employers and bodies such as the Scottish Social Services Council and the Care Inspectorate, around 100,000 of the people in the workforce are registered and have or are working towards the qualifications required for their role, and their fitness to practice can be regulated. That is progress. We are also working with partners on the social work services strategic forum and the human resources working group on integration to support a range of actions to strengthen the workforce and demonstrate how much it is valued.
We are clear that we cannot do this work alone, so the committee’s interest in the area provides a timely opportunity to consider the progress that has been made and the challenges that we need to work on together with all our partners, many of whom the committee heard from at its evidence session on 13 September.
Thank you very much, cabinet secretary. We will now move to questions.
I have a specific question about Brexit. Annie Gunner Logan, who represents voluntary care providers, told us—I am speaking from memory—that, when she asked her staff about the implications of Brexit, they mentioned that it provided an opportunity to lessen the burden of rules on procurement and tendering. Do you have any observations about that?
Whatever constitutional arrangements we have, there will always be rules on procurement and tendering because of the need for openness and transparency, and to ensure that due process is followed and seen to be followed in the spending of public money.
On the impact of Brexit, given where many of the workers in social care come from, I am extremely concerned about the potential loss of workers from other parts of Europe who support our care services, particularly in the care home sector. We should all be extremely concerned about that. Again, I take the opportunity to send the social care workforce the message that, no matter where they come from, their work here is valued and we want them to remain working here, whether that be in our care home sector or our care-at-home sector.12:00
On that subject, the panel of witnesses that we heard from two weeks ago said that one of the problems was that it was hard to estimate the number of non-UK EU nationals working in the social care workforce. Is the Government doing anything to establish what those numbers might be?
I will let Geoff Huggins respond in a second, but if you go round the care home sector in particular—this is also true, to some degree, of the care-at-home sector—and speak to the staff in care homes the length and breadth of Scotland, you will find that many not only in our social care workforce but in our nursing workforce have come from other parts of Europe. That is very visible to me.
Alan Baird probably has a bit more data and information on the numbers, but I do not think it unreasonable to say that the loss of that cohort of staff, who do a hugely important job here, would be a blow to the sector that we would want to avoid. That is why I am sending the message that we value them and want them to remain working here in the sector.
Alan, do you want to say a word about the make-up of the workforce?
As I think was noted in the meeting on 5 September, we do not currently know the number of people in the workforce who come from the EU and beyond, but I think that that is something that we will increasingly need to understand in order to look at the potential gap in social care.
Did you want to come in here, Geoff?
I want to make two points. First of all, Annie Gunner Logan made an interesting point about procurement, because part of the challenge that we face in delivering the living wage is the legal framework within which we can specify contract rates. There is therefore a question about what would happen next in the context of Brexit. The other component is that we do not know whether the next step beyond Brexit would be a reserved or a devolved matter, and if it were a reserved matter, how it would be handled in the broader context of UK policy on earnings.
We are certainly conscious of the issue in respect of non-UK nationals in the workforce and, in that space, we would also be careful about the degree to which that patterns in different ways across the country and how likely it is to affect different components of service delivery differently across Scotland, particularly—and I think that the committee has previously taken evidence on this—in island authorities as well as more remote and rural authorities, especially those in the north-east.
We are and will be discussing this area with the partners group, which comprises not only providers but Unison, and with which we have been working more generally on taking forward some of the reforms. The issue is right in front of us at the moment.
I think that Sarah Gledhill is going to say something about data collection.
As I am sure you know, the SSSC collects annual data on the social services workforce, and we are discussing with it whether we might be able to add a question that will enable us to collect more accurate information on this topic.
Picking up on something that Geoff Huggins said, I wonder whether you can give us an update on progress in implementing the Scottish living wage across social care.
Before Geoff Huggins comes in on that, I should say that people have been working hard across the partnerships to ensure delivery from 1 October, and I put on record my thanks to all of them for doing so. After all, it has been quite a big undertaking. A lot of hard work is being done, and I think that we are in a good place.
As the evidence that you have heard previously suggests—I imagine that you are also hearing this separately—this is a remarkably challenging undertaking. We are working on it directly with the Coalition of Care and Support Providers in Scotland, Scottish Care, Unison and the Convention of Scottish Local Authorities; indeed, I spoke to CCPS and Scottish Care this morning to get an update from them and to share our understanding of what is going on. We are therefore working carefully across partners to triangulate what is happening in local negotiations and, from that, to get a national picture.
We know that good progress has been made in many areas; in other areas, negotiations are continuing. Part of the challenge is that it is not a question of simply finding the right number and then rolling out the policy; the process is built up of hundreds of local negotiations with individual providers, who have historically offered different terms and conditions to their workforces. It is not a small-scale undertaking.
On the basis of the work that we are doing, including with individual partnerships, we are confident that there is progress. I speak with chief officers and procurement officers regularly, so that I can understand what is going on and ensure that we deliver the commitment. It is clear that we are still resolving some issues locally. However, we are confident that we will meet the commitment that the benefit of the living wage will be achieved from 1 October.
I presume that lessons will be learned from the approach that has been taken so far. You have said that you will be working up to the 11th hour to ensure that everyone gets the living wage from Saturday.
The committee took evidence from Annie Gunner Logan, who pointed out that providers were not consulted on the implementation of the policy but read about it in the newspapers. What will you do in future to involve stakeholders in developing policy, to ensure that it is sustainable in the long term?
It is widely recognised that the Scottish Government’s estimate of £37 million was very much an underestimate of the cost of the policy nationally. What assessment will you make of the cost of implementing the policy from 1 October, as we hope will happen?
I am keen for clarity on payment for sleepover shifts. Is it the Scottish Government’s position that sleepover shifts should be paid at the living wage rate? Will that be the case from 1 October? If not, when will that happen?
Part of the £250 million that we have provided for social care is for the delivery of the living wage. It is an ambitious undertaking—Geoff Huggins outlined some of the complexities—but I think that there has been a willingness and a determination on the part of all partners to make it happen, because it is a good thing, which will encourage people to stay in—and, I hope, enter—the caring profession.
The complexity arises partly because the area is subject to negotiation by the local partners who commission and procure services. They are the ones who must deliver the mechanism for paying the living wage. We have provided the resources, but the mechanics of the approach must be delivered locally. Partnerships in some areas were further along the road towards the living wage than partnerships in other areas, so the distance to be travelled has been different in different areas, which has meant that different resourcing has been required in different areas. Things will become easier, I think, because we now have data that we did not have before, at local and at national level.
I think that the policy can be sustained in the long term. As I think I said to you during the parliamentary debate on health, our discussions with COSLA and partners in the care sector are partly about ensuring in the spending review that the living wage continues to be delivered. That is an important priority for us.
You asked about sleepovers. That issue is still being discussed, because of the complex way in which sleepover payments are made. Partners have asked for more time, and I understand that the unions have been party to the discussions to ensure that the issue is resolved. It will take more time to resolve that, and we will help and work with local partners to ensure that the discussions are taken forward as quickly as possible.
You asked about lessons learned. As the cabinet secretary said, we have asked partners to use the existing system for retendering and renegotiating. We have taken four or five elements of learning out of that to think about for next year, because we will be looking to think about how to approach this as time moves on.
A key component is the change in the nature of the relationship between commissioning and procurement. Historically, this would have been a local government commissioned and procured service. It is now an integration authority-commissioned service and a local government-procured service. That gives us the opportunity to discuss how we might take forward the procurement differently now that it is separate from the commissioning role. That is a key change that has taken place under integration.
For some of the more niche providers in learning disability or mental health who provide across a number of integration authority areas, we are looking at whether we should be considering a lead procurer and at the challenges of similar providers being made different offers from adjoining authorities. We are learning the lessons: we talked about those with the chief officers when we met them 10 days ago, and it was on my agenda this morning for the discussions with Annie Gunner Logan and Donald Macaskill.
On the cost assessment, the information that we lodged in the Scottish Parliament information centre at the end of 2015 was very explicit about the presumptions that had been made. Some of those presumptions were questioned when the committee last met. It would have been challenging to have involved the providers in the negotiation between the Deputy First Minister and COSLA on the local government settlement, although we understand their frustration about that.
As part of that process, we invited local partnerships to consider what they believed the local cost would be and offered our information as support to the process by which they considered the use of the £125 million. Although we put information into the system, we did not say, “This is the figure”. We gave a figure based on particular presumptions and the knowledge that we had, and we invited local partnerships to make their own assessment of the appropriate cost. Most appear to have done that adequately.
We are also talking about the process of involvement for the next round. We think that the process that we have built with the partners group, which involves the Scottish Government, COSLA, CCPS, Scottish Care and the unions, is a good methodology for future years.
I understand fully the complexities of having 7,000 social care providers across Scotland and 31 IJBs. We have a national framework for care homes. Is any consideration being given to a national framework for care at home?
That is probably less straightforward. Although the majority of the service is for older people—it covers things such as personal care and assistance with daily living—it becomes more challenging to consider the idea of a single rate that covers a range of other complex services such as those for substance misuse, learning disability and mental health. There are also different ways in which services are stitched together locally between health and care, which means that the burdens that fall on social care and health services might be different depending on where you are.
As part of the reform process, we are looking at those questions, but the issue might be less straightforward than it is for residential care. Indeed, the work that we are doing on residential care is raising the question of whether we need different approaches for the various forms of residential care. Ultimately, the objective is to provide and fund services in a way that supports the different needs of individuals, rather than reducing them to a common minimum.
One of the biggest impacts on the workforce planning environment, aside from that of integration, has been from the advent of self-directed support. I would like to hear the panel’s reflections on how that has impacted on workforce planning. A number of us have received briefings from health boards about provider behaviours in response to self-directed support that have not been entirely helpful. Will the witnesses reflect on the impact of self-directed support on the workforce planning agenda in social care?12:15
I was the Minister for Public Health when we were in the initial stages of taking forward the concept of self-directed support and during the passage of the legislation that followed. Out of everything that has been done, that has the potential to be one of the most innovative programmes and concepts. It is all about empowering people, putting the person in the driving seat of their care and ensuring that they are involved in building the services around them, rather than having services provided to them that do not meet their needs. The concept is fantastic, but to be honest it is work in progress. We have provided a lot of support to make it happen and resources have gone in to ensure that we embed the whole process of self-directed support across the social care sector to build the workforce, and to ensure that anyone who wants access to self-directed support to deliver the care that they need can have access to it.
We are in a better place than we were previously with the whole culture of accepting self-directed support. Initially, there may have been a bit of resistance, because people thought that it might threaten the statutory service model in some way. That is less the case now—people have accepted that it is a good option and not a threat to existing services but an enhancement of them.
Geoff Huggins may want to say more about that.
We have found self-directed support being used in innovative and novel ways, particularly in rural communities. One of the examples that I often give is the Boleskine Community Care model, from the banks of Loch Ness—an area where it was difficult to recruit a social care workforce or persuade people to travel the required distance. Instead, people in the community were identified who were prepared to do a few sessions a week using self-directed support to provide care for others who lived in their neighbourhood, and that worked effectively.
Alex Cole-Hamilton identified provider behaviour as an issue, and I will be interested to see what happens in that regard. I would assess it as being largely driven by the previous approach around compulsory competitive tendering. We will see whether that is a continuing factor as we move away from the focus on price towards quality being the dominant factor, along with pay increases and the values of contracts changing. There is a question as to whether that behaviour, as a reaction to CCT, will continue to be as forceful. The comments in the Auditor General for Scotland’s report last week on the impact of CCT are helpful in that regard.
The bigger challenge with some services, such as day services, is the increasing diversity in the support that people are looking for. That will be difficult to work through, but we need to do it.
The Scottish Government has invested £58.6 million in the transition to SDS between 2011 and 2016-17, and some of that has been around building the workforce and the innovation fund. Alan Baird can tell you more about that.
I have spent quite a lot of time in recent months visiting large providers such as local authorities and smaller organisations in the third sector, and I have met a cross-section of front-line social workers to hear about their experiences. We are halfway through a 10-year strategy. As the cabinet secretary has said, it is a complex undertaking. The Government provided a considerable amount of money to put in place the right infrastructure and, as a result, we have made really good progress.
Those who are in receipt of self-directed support—people who are making the right opportunities from the choices that they have—are seeing their lives change in innovative ways. However, national providers get really frustrated about the number of sets of forms that exist across Scotland. National organisations work with a number of local authorities. For example, a provider that works with 10 local authorities can expect to get 10 sets of forms, which is time consuming. There is a sense of frustration, given the current resources and the level of self-directed support that there ought to be.
We are making really good progress. Those who are in receipt of self-directed support sometimes say that there is an issue when the amount of money they get has been reduced. Some see that as part of the austerity that local authorities face. The other side of that coin is that self-directed support is working well and that, because the needs of the individual have changed, they no longer need the level of provision that they may once have had with self-directed support. We are learning a great deal as we progress and we need to use the coming months and years to pick up on some of the emerging issues.
Colleagues including Maree Todd and Donald Cameron have raised the issue of the potential impact of Brexit on the workforce. We are discussing the move to care in the community, but the whole thing is predicated on our having enough social care staff.
The SSSC spoke about a survey of employees that tried to understand better where people come from, but it seems that there is a dearth of definitive data on the number of EU nationals working in the NHS and in social care. What steps is the Government taking to establish that number and what contingencies are being put in place in case EU nationals do not have an automatic right to remain after EU withdrawal?
That is a little easier with our medical and nursing workforce, because we have the data, as do the regulators. Therefore, we can provide more definitive information about the medical workforce, and we have done so. The numbers are a concern.
As you heard earlier, the situation is less clear with the social care workforce, because the gathering of information is work in progress. As Sarah Gledhill said—she might want to expand on this—we are looking at including additional questions on the workforce survey to try to gather more information about whether people are EU nationals or, indeed, where they come from more generally. That would be helpful.
I ask Sarah whether we can give a timeframe for that.
Over the next couple of months, discussions will take place with the SSSC on whether we can change the data collection for the next round of data. We are also considering whether we need to do something more urgently or in the shorter term. The SSSC publishes data retrospectively, so there is a bit of a time lag between the data being ready to publish and the year that it refers to. We are looking at whether we need to do an exercise shortly, and whether we should include a further question so that, going forward, we collect the data needed to answer that question.
Perhaps we could write to the committee with an update.
We could do that, once we are clear about what we will do. That would be fine.
That would be helpful.
I have a question about care home places. Audit Scotland has said that Scotland will require an estimated 20,000 additional care home places by 2030. The answer that I received in response to a parliamentary question shows that Scotland has lost 3,600 places. We have heard from private sector providers that they are finding it difficult to sustain the service. What work is being undertaken to ensure that Scotland is adequately supplied with the care home places that we need?
The make-up of care home places and what we use care home places for have changed over the years. We have worked closely with Scottish Care on that change.
I was a home care organiser in a previous life, and it was not unusual for people to go into a care home setting when they were still quite fit. That was for a variety of reasons; it was a different culture. People’s ability and desire to stay at home have changed—their outlook has changed. Without doubt, the demand now is for people to remain living in their own homes with appropriate support.
That has led to a change in the care home sector. There are now fewer places and there has been a change in what those places are used for. Our discussions with the care home sector have been about needs now and in the future. We will need more intermediate care and we are looking at what the sector can provide. There are great examples of that. We have hugely expanded the number of intermediate care places, many of which are located in a care home environment. That helps to put the care home sector on a more sustainable footing and provides what is needed. It also provides a service that is a step down and potentially a step up—although that is less developed—between home and hospital. That is a really important development.
It is fair to say that the people who end up in permanent care home places now have far more complex needs than previously. A lot of people have complex needs with dementia, which has meant a change in the number of places that are provided and in the care staff ratios that are required. Those are not necessarily negative developments; they are a recognition of the changing needs of the population. There is change in what people demand and the sector needs to adapt to meet that, and we want to help it to do so.
The evidence from NHS Greater Glasgow and Clyde was that it is using the private care sector in Glasgow to help to tackle delayed discharge. There was a concern that the potential loss of private sector beds could have an impact on the acute setting. We need to be aware of the unintended consequences of Scotland losing places.
We need to have the right number of places in the right areas to meet the needs of the population. All I am saying is that that is changing. With regard to that development in Glasgow, I have visited one of the care homes that is providing that intermediate step-down facility. It is a fantastic service that meets the needs of the acute sector to reduce delayed discharge and provides stability and sustainability for the care home sector. It is different from the role that the care home sector has traditionally provided, but the sector has embraced that well.
The Glasgow example is interesting, as it shows leverage. By working in that way, more people have returned home than would have been the case historically, which is what people say that they want. The Auditor General’s report was careful in saying that it was about what would happen if nothing changed and things continued as they are. Throughout, the report stunningly makes the case for reform. It says that there is a need to think differently about how we approach care and how we meet people’s needs.
With each of the partnerships that we are talking to at the moment, we have identified the idea of using more hours to support reablement and step-down. An increase in people’s capacity to continue to care for themselves is core to the changes that we are seeing.
Reablement is really important. In my previous life as a home-care organiser, a person’s needs would often change because of a fall. They would come out of hospital and the things that they had taken for granted and done for decades for themselves would suddenly be done by somebody else. With reablement, they can get back those independent skills. The thought processes on that have completely changed, for the better.
To clarify the figures on the number of care homes, although the total number has fallen by quite a lot—17 per cent in the 10 years since 2006—the number of registered places has fallen by only 3 per cent and the number of residents has fallen by 4 per cent.12:30
The figures that the cabinet secretary provided in a written answer to my question suggest that there are now 42,026 places in Scotland, which is down by 3,695. Given what Audit Scotland has said about an extra 20,000 care home places being required, there is concern that the direction of travel on the number of places is down.
But it is about what we use the places in the sector for. There has been a big increase in the number of hours of care at home provided each week. That care is going to fewer people, because the complexity of the needs of people who remain in their home has increased, so their packages are greater and the number of hours overall has increased. We are seeing a shift towards people remaining in their own home for longer, so the type of service that the care home sector provides is changing. We want to work with the sector to help it to provide a sustainable service that meets the needs of an ageing population.
I will ask one final question before we finish, because it is a really important one. One of the most valuable and informative sessions that the committee has had was the one a few weeks ago with social care workers from residential care and home care. How do we make a career in care more attractive and a more valued career choice in our society?
That is probably the key question and the most important one. We must ensure that we value the caring role and the people who work in the care sector, whether it be in people’s homes or in a care home. The living wage and what people are paid for the role are important components, as are some of the surrounding terms and conditions, so it is important that we work with the sector to try to improve those. It is also about career opportunities and progression. In the world of integration, we are seeing some innovative ways of linking opportunities in health and care so that, for example, should someone who comes into the care sector have an ambition to end up working in a regulated profession, they can make the transition in a more coherent and structured way and there is a pathway. That will not be for everybody but, for many, it would be quite an attractive way to come into a regulated profession such as nursing.
We can furnish you with examples from across the country. For example, NHS Western Isles is taking the approach that I have described because it recognised that it needed to develop and deliver its own workforce, as it could not wait for people to pitch up from elsewhere to meet the needs of its population. One way that NHS Western Isles is doing that is to encourage people in its communities to think about health and care as a profession and to provide pathways through one into the other, should that be what someone wants to do. We need to get better at that. We are working with NHS Education for Scotland to develop more coherent pathways through care and health and to share the training opportunities that exist in the NHS so that care staff can link into them.
I draw members’ attention to “Social Services in Scotland: a shared vision and strategy 2015-2020”. One of its four sections is on workforce and—as the committee heard two weeks ago—it is about valuing the workforce. It is also about how we recruit and retain much better. A lot of work is going on because we anticipated as a sector—some of the people who the committee spoke to two weeks ago are part of the process—the need to take forward work on the quality of social care in Scotland and the value that is placed on the workforce.
I thank the cabinet secretary and the other witnesses for their time this morning.12:34 Meeting continued in private until 12:46.
PreviousGeneral Practitioners and GP Hubs