Public Audit Committee

Meeting date: Thursday, April 21, 2022

Official Report 656KB pdf

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“Social care briefing”

We have two evidence sessions this morning. The second is with the Auditor General for Scotland on the report on the new vessels for the Clyde and Hebrides. However, before that, we will take evidence on the Audit Scotland briefing on social care that came out recently.

I am delighted to welcome our four witnesses, who join us online. We are joined by Caroline Lamb, who is the chief executive of NHS Scotland and the Scottish Government’s director general for health and social care, and Donna Bell, who is the director of social care and national care service development in the Scottish Government. We are also joined by two representatives from the Convention of Scottish Local Authorities: Nicola Dickie, who is the director of people and policy, and Sarah Watters, who is the director of membership and resources.

We have a series of questions to put to the witnesses after we hear short opening statements from Caroline Lamb and Nicola Dickie. Given that the witnesses are online, they should use the chat function to indicate if any of them wants to come in and we will do our level best to bring them in. If Caroline Lamb or Nicola Dickie wants to bring in Donna Bell or Sarah Watters, they should let us know and we will ensure that they are called in.

I invite Caroline Lamb to give us a short opening statement.

Thank you very much, convener.

The Audit Scotland briefing acknowledges that our commitment to a national care service indicates our recognition of the significant challenge in social care in Scotland. Indeed, the findings of the briefing were largely in line with those of the independent review of adult social care, led by Derek Feeley, which is precisely why we are acting to further increase investment in social care and deliver a national care service by the end of this parliamentary session.

Ministers are clear that we should not wait to establish the national care service in order to take action where it is needed. Therefore, we will increase public investment in social care by 25 per cent over this parliamentary session so that, by the end of the session, we will have budgeted more than £800 million of increased annual support for social care compared with current spending. In the latest programme for government, ministers restated their commitment to transformative social care reform, including developing options for the removal of charging for non-residential adult social care.

Importantly, we also agreed a joint statement of intent with COSLA in March 2020, in which we agreed to work together to advance the key foundation principles of the independent review. That commitment included work on many of the areas that Audit Scotland identified as requiring improvement.

Along with my colleagues, I am happy to answer questions on any of those areas and, in particular, to expand on the action that we have taken, and continue to take, to support the attraction, recruitment and retention of the workforce, on data improvement, on self-directed support and on the development and implementation of the healthcare framework for adults living in care homes in Scotland.

Throughout that work, we are committed to listening to the voices of people with lived experience. Those conversations are already influencing our review of self-directed support. Keeping people with lived experience at the heart of our decision making will help us to shape a system that will improve future services and make things better for everyone.

Thank you very much for that opening statement. It covers many of the areas that we want to probe in our questions.

I invite Nicola Dickie to make her opening statement.

Thank you for inviting us to discuss Audit Scotland’s “Social care briefing” and the stark but important issues that it highlights.

We know that the pandemic has put exceptional pressure on the whole system—the entire workforce, unpaid carers and those with lived experience of accessing social care support. We also know that many of the issues highlighted by Audit Scotland are not new; they are in many ways issues that we have consistently highlighted for many years as requiring meaningful attention and whole-system preventative investment.

As COSLA has stated for many years, there is a pressing need for national and local government, as well as our partners in the social care sector and trade unions, to work in partnership at pace, given current pressures, to address those challenges. Local government recognises that we cannot stand still if we want to create meaningful change and improve outcomes for people in the communities that we serve. We also know that we cannot wait for the creation of a national care service, nor can we be distracted by the challenges that come with the proposed structural reform.

We are committed to acting now and implementing much of the change that is called for in the briefing. As Caroline Lamb alluded to, in March 2021 COSLA and the Scottish Government committed to a joint statement of intent, which set out the ways that we will work together to deliver on the key foundation pillars that were set out by the independent review of adult social care. Fundamental to the statement of intent was the recognition of the importance of empowering people, valuing our workforce and embedding a human rights-based approach to social care.

We have continued to work jointly to deliver on that through progressing the recommendations of the Fair Work Convention’s report on social care and working to ensure that the commissioned social care workforce gets improved pay and conditions and a career that fosters continuous learning and development. Ensuring a stable, skilled and valued social care workforce is a key priority that COSLA and the Scottish Government share.

However, many of the issues that require reform are not simple and have been challenged by the on-going and significant pressure caused by the pandemic, as well as on-going pressures on core local government funding. Progress has not happened at the pace that we would wish to see, and there is now a shared sense of urgency across the system to address that. Put simply, local government is trying to deliver more with less.

However, I urge committee members not to consider the social care sector in isolation from the whole system. Many of the services and supports in our local communities that keep people healthy, connected, engaged and happier are the wider determinants of health that prevent individuals and carers from reaching crisis point.

Investment in local government is investment in prevention and wellbeing, which is why we share the ambition with the Scottish Government that everyone in Scotland can live well locally; that is reflected in COSLA’s local government blueprint and the recent programme for government, which Caroline Lamb mentioned. Local government is at the heart of that ambition, but we need fair funding to achieve it, and I am sure that we will pick up some of those issues in more detail. I look forward to discussing some of those points in more detail with members.

Thank you for that opening statement. I will invite committee members to come in with questions, but I will begin by reflecting on what the Auditor General told the committee when he appeared on 3 March to talk about the social care briefing that he produced. In his opening statement, he said that

“The Scottish Government needs to take a pragmatic approach and set out what can be improved now, without legislation, while taking time to determine where the national care service can add most value.”—[Official Report, Public Audit Committee, 3 March 2022; c 3.]

You have both spoken about the statement of intent and joint partnership proposals, but what is happening right now? What is your action plan and what steps are you taking at the moment?

The joint statement of intent that was published in March 2020 had a number of key aspects, which Nicola Dickie outlined. In his evidence, the Auditor General had a clear focus on workforce, data and collaboration. We have worked with the fair work in social care group to develop minimum standards frameworks for terms and conditions. Those have been fully agreed and identified and we are working with COSLA and other partners on the most efficient and effective mechanism for enabling them to be delivered. Part but not all of that is about rates of pay, and the committee will be aware that the Scottish Government has provided funding to increase the minimum hourly rate from April. That is pegged for social care workers to £10.50, which is an increase of 12.9 per cent from £9.30. It stood at £9.30 then went up to £10.02 in December, and it will go up to £10.50 from April. That represents real progress.

We have been taking a whole load of other actions on top of that in relation to the workforce, and I would be happy to talk through those now, although I am conscious that it might take a wee while to get through them all. There has been a lot of activity around attraction, including national recruitment campaigns; waiving the costs of the myjobscotland recruitment portal, which has had more than 40,000 clicks on the apply button since that happened; waiving the costs of registration with the Scottish Social Services Council and checks under the protecting vulnerable groups scheme; and accelerating PVG checks so that we can get people who are applying through that process into social care faster. We have also set up a round table with employers to discuss how best to use recruitment fairs, and we are currently running a series of recruitment fairs, supported by the Department for Work and Pensions.

We have considered the impact of the changes to freedom of movement, and we note that care workers have been added to the shortage occupations lists. There are challenges around that, however, as many people in the workforce are employed part time.

We have considered what we can do to improve the valuing of the workforce, with good, strong opportunities for development and career progression. We have worked with NHS Education for Scotland and the SSSC to establish an induction package, which went live earlier this year, and we are continuing to work around routes into social care, including flexible routes that will enable people to develop their careers within the sector up to the levels of advanced practice.

A huge amount of work has been delivered in partnership in that area in relation to some of the issues that the Auditor General identified around workforce. We have also made progress on data, which is one of the areas that he highlighted. I can come back to that. I am sure that you have questions on a number of other areas, and I do not want to pre-empt all of those. I will therefore pause there, although Nicola Dickie may wish to pick up on some other areas.

Thank you. I will bring Nicola Dickie in. We view the briefing as focusing, quite rightly, on the value of the workforce, and we have some questions on that. The briefing addresses other areas, too, such as the voice of service users, how the whole commissioning model is working and whether it is delivering what we want to see.

We are under some time constraints, and we will come to those areas in time, but I want to give Nicola Dickie an opportunity to answer the question that I put, on the pragmatic approach and on what practical steps are being taken now.

I will not go back over what Caroline Lamb said. As she rightly mentioned, the work on increasing the hourly rate and so on was all done in partnership: local government and the Scottish Government worked in partnership to deliver that.

There are two things that I want to bring in on top of that. We had a critical period with omicron just before Christmas time, which involved local government redeploying and shuffling in staff from the wider local government workforce to support the social care workforce. That involved keeping staff within our own services, but also moving them into commissioned services where that was required. That was a practical way in which the rest of the local government workforce, and local government as a whole, has supported social care—although I appreciate that that was specific to omicron.

I also want to mention working in partnership at the start of this year. We have published the “National Workforce Strategy for Health and Social Care in Scotland”, which is an integrated strategy.

Those were the two things that came to mind after Caroline Lamb gave the list of things that we have done jointly.

Thank you very much. My next question is whether you both accept the recommendations in paragraphs 35 to 38 of the Audit Scotland briefing. Do you accept the recommendations that are set out there?

Yes, I think that the Scottish Government accepts the recommendations and has already taken forward action with partners in many of those areas.

09:15  

There is nothing in the general report that COSLA would disagree with and, as Caroline Lamb has alluded to, we were already actively working to address many of those issues. Donna Bell might want to come in on the specifics.

Donna, do you want to add to that?

All that I would add is that all the themes that Audit Scotland identified are very much on our radar, so I agree with Caroline Lamb that there is nothing in the report that we are not already aware of or are not already working on.

We will return to some of those themes as we go on. The concern that we have—and one of the threads that runs through the Audit Scotland report—is the need for a sense of urgency and an understanding not just that the matter is on your agenda but that there is an action plan with force behind it, which is leading to change.

I invite Craig Hoy to ask a series of questions.

Good morning, everyone. Through its plans for a national care service, the Scottish Government is planning significant reforms to social care, which will extend beyond residential social care. The commitment to proceed with reform seems absolute, but the planning for that reform is still at an early stage, and the ink is barely dry on the consultation. However, while we move towards those reforms which include wide-scale structural reform, it is clear that there are significant urgent needs now. What levels of investment are required, in the short term, to meet today’s needs and, in the long term, to implement future social care reform? Given that, over the past decade, local government in Scotland has been chronically underfunded by the Government, do you have confidence that the funds will be forthcoming to meet the short-term needs and the long-term structural requirements? That question goes first to Caroline Lamb.

Thank you for the question. As you said, the national care service is a really ambitious and important reform, and the pandemic has made the case for change even more urgent, in shining a light on some of the issues in social care. Therefore, we are committed to establishing a functioning national care service by the end of this parliamentary session.

As you said, the ink is barely dry on the consultation, and ministers are considering the wealth of information that came in through that consultation. As we think about the next steps, we continue to engage with people who access and deliver services.

As I have already indicated, we are committed to increasing by 25 per cent the level of investment in social care over this parliamentary session. As part of our work around planning the detail of a national care service, we will, of course, assess exactly what will be required, not just in relation to funding but by looking at the service across the whole health and social care system. For example, we will look at where there are opportunities to shift expenditure towards community services, so that we can get into a more preventative, proactive space.

I do not know whether Donna Bell wants to add anything to that. [Interruption.]

Donna, do you want to supplement Caroline’s comments?

I think that we might have lost the connection with Donna.

We will go back to you, Craig.

From a COSLA perspective, Nicola Dickie might want to reflect on the financial pressures that local government has experienced recently and what might happen during the interim period, when we might see a significant hollowing out of local government, as social care is moved under ministerial control.

I will give you my opinion from a social care perspective and I will bring Sarah Watters in on the wider finance point. We have to think about what we want the current system to achieve. Caroline Lamb has already mentioned that Scottish ministers have made a commitment to increase spending by the end of the parliamentary session. From the perspective of local government and the perspective of people who access services, it is about whether we are comfortable that the existing social care system will continue to deliver what it is delivering now.

The Auditor General’s briefing recognises that thresholds and access to services are at a high level, so a 25 per cent increase in funding by the end of the parliamentary session is welcome. However, I am not sure that we are comfortable that that will achieve more than we are achieving within the existing system.

COSLA discussed the finances associated with the national care service extensively with Derek Feeley when he did his independent review of adult social care. We discussed both the funding in the current system and the wider local government funding that supports social care. If you asked me to describe it, I would say that local government funding is the branch of a tree, and that social care, health and public health hang from the branch of core services provided by local government. Many of the services that are provided by local government do much to improve the lives of those who access social care.

We need to ask whether we are comfortable that there is enough money in the system for the current social care system—we recognise that improvements need to be made—and whether the 25 per cent increase is enough to help us deliver what we are delivering at the moment. There is a question mark over that.

It is difficult to say whether the associated funding that Government ministers have suggested will be required for the national care service will be adequate, because Derek Feeley only costed adult social care, and now we have proposals on the table that bring in other things. It is difficult to give a figure for what would be adequate, because I do not know exactly what will be included. As Mr Hoy said, that is, quite rightly, because the consultation has only just finished. The bill will have a financial memorandum, which COSLA is very keen to see, as you would expect.

I will bring in Sarah Watters to talk about local government financing more generally.

Thanks, Nicola. I am happy to come in on that.

One of the fundamental points that COSLA has continued to make—we made it quite clearly in our submission to the resource spending review a couple of weeks ago—is that, although we accept that more cash has gone into local government over recent years, and we cannot argue with that, general revenue and core grant funding from the Scottish budget has flatlined since 2013-14.

The problem is that, if there is inadequate policy funding for the commitments that are already in the system, to which we add the new funding on top, we have to take money from core funding to prop up commitments that have not been funded and or when demand or cost increases. The real pressure point is that flatlining of core funding. Audit Scotland highlighted in its local government finance overview that there has been a significant real-terms cut, although increases have actually been passed to the Scottish Government and other parts of the wider system.

The whole thrust of COSLA’s campaign this year was about saying that other services in communities are what keep people out of the national health service and what could, ultimately, keep them out of the national care service or keep them at the lowest level of care required. Instead of costly complex interventions, we need to look at some of the simpler things that we can do upstream in services such as lunch clubs, community learning, mental health support and transport. That is where core funding is the issue.

The wider issue of extracting social care from local government is an extremely complex one. Some services, such as catering and cleaning services, are inextricably linked to other council services. A catering service might cater for adult social care, schools and other local government services. A whole range of council services, such as transport services and support services, are back-office functions, which—as the Auditor General pointed out when he provided evidence on the local government benchmarking framework—have taken a hit over the years. It will be really complex to unwind some of that and extract those services from local government without there being a detrimental impact on local government

The Auditor General draws attention to that in his briefing. Stakeholders raised concerns not only about extracting adult social care but about the wider scale of the reforms and the impact that they could have on local government.

The financial tension is significant. The other tension is that, during the structural reform process over the next three to five years, the urgent need in social care that the Auditor General identifies in his briefing might somehow be pushed out because of the process that will need to be undertaken.

Caroline Lamb, what assurance can you give the committee that there will be a clear timescale for developing a plan to address the urgent issues in the system? How will it be possible to implement longer-term reform, for example when councils allocate capital budgets or in relation to the reprovisioning of care services? Is there not a real risk that, because of the longer-term structural review, those issues will be pushed off the table even though, in many respects, they are urgent?

We are absolutely focused on the immediate and urgent pressures. In our winter response plan, we announced £300 million of additional funding, of which £170 million went into social care in recognition of the absolute interdependence between health and social care. We need all bits of the system to deliver the best value that they possibly can.

Although I understand the focus on budgets, budget management and resources, it is also important that we look at the outcomes and quality that we deliver for people. We need to ensure that we spend the money that we have in the best possible way to achieve the best outcomes for people. As long as all of us across the system remain focused on achieving the best outcomes for people, we will continue to improve the system as we move towards reform.

Reform of the scale that is necessary will involve significant changes to governance, accountability and collaboration, and will require some degree of new leadership. To what extent can the Scottish Government learn from previous wide-scale reforms and avoid having a Police Scotland mark 2 as the product?

We are mindful of the way in which policy has not been implemented as well as we might have liked in the past and of the need to learn the lessons from previous large-scale reforms—the establishment of not only Police Scotland but Social Security Scotland, for example. We need to learn the lessons not only from what has gone well but from the things that have not gone so well.

I ask Donna Bell whether she wants to come in on those points.

We have discussed urgency and the need for a coherent plan for improvement. As Caroline Lamb has described, a number of actions are under way around self-directed support reform. We have a really good collaborative group of people working on that to develop an improvement programme. We have already covered many of the recruitment and retention challenges and the actions that we are taking on those. A range of other work is focusing on residential settings for adults, particularly those in care homes, and the healthcare framework that we propose to implement in such settings.

We are also working on a different practice model to support an holistic approach to people. The work on multidisciplinary teams that will support that has been moving forward at pace over the past year or so.

Next week, we will meet local government colleagues to discuss wider improvements. Nicola Dickie might want to comment on this, but the commitment from the Scottish Government and local government to draw together that coherent improvement programme and implement it at pace post the local government election is absolutely at the top of our agenda.

09:30  

On learning from previous reform or change, we have done a significant amount of work to learn from the integration of health and social care thus far. We also engage regularly with the people who undertook police and fire reform and the setting up of the social security agency and with others to understand what has worked really well for them, as well as the things that they might want to do differently in the future. We have a good cohort of colleagues and are getting advice on major reform programmes and change management.

We are drawing all of that into our discussions about not just the future national care service but the reform that we want to undertake now and the improvements that we want to make.

I have a brief final question about how data gaps are going to be addressed. It is clear that there are data gaps in relation to demand and unmet need, for example. How do you intend to plug those gaps now and as you move forward to a more integrated system with social care and the NHS? How will you align and integrate the data so that you get a better product in the end?

Data is an area that I have a particular interest in. In the NCS consultation we set out a plan for a nationally consistent, integrated and accessible health and social care record, with the intention to use legislation to ensure appropriate sharing of data—and data standards, which make it so much easier to share data. That is another thing that we cannot wait for—indeed, we have not been waiting.

We have made important progress during the pandemic and through the pressures that we faced. To give one example, we implemented the Turas care management safety huddle tool in care homes, which provided information that was absolutely critical to our pandemic response. It provided a timely standardised data set for each adult care home across Scotland, which has been incredibly useful to providers, oversight groups, health and social care partnerships and us nationally.

That sort of work has made and continues to make a difference. There is also a big focus on taking the work out of data collection. The system is a very simple one—it does not consist of lots of complex spreadsheets.

We have implemented a data improvement programme and we are working with partners to identify the barriers to achieving improvements in the short term and as quickly as possible.

You referred to data gaps across the health and social care system, and the focus on management information is critical. I have already mentioned the interdependencies across health and social care. In understanding how we can best make the system work for people, we absolutely need to understand what the pressures are and what the demand is at each point in the system. Particularly in relation to the pressures that the system has been under, our adult social care gold group has worked in partnership to develop key sets of management information, which is helping our understanding of how the system is working end to end. There is still work to do to improve the quality, timeliness and consistency of data—I do not underestimate the challenge—but that is something that all partners are committed to working on.

I do not want to use up too much time now, but I hope that I will have the opportunity later in this evidence session to talk about what the data is starting to mean in real life for people working in the system.

Donna Bell also wishes to come in on that point.

I will pick up on the point that Caroline Lamb made about the gold group, which is a multi-agency group that was brought together during the pandemic so that we could gain a better understanding of the issues that are emerging and that are live for us all.

There has been a significant focus on data, as Caroline Lamb said, specifically around outbreaks in care homes, pressures in the system, unmet need, workforce absence, workforce supply and so on. Nicola Dickie might wish to come on this, too, but that focus has certainly given us a better shared understanding of the pressures in the system over the past year.

As Caroline Lamb said, there is a lot more work to do on quality and to significantly expand that data set, because at the moment it captures known unmet need at a management information level—people who are waiting for assessments or packages of care—but it does not cover wider unmet need in the community at a more preventative or early intervention level. There is a significant amount of work to do, but we have made a lot of progress over the past year.

As I mentioned at the beginning of the meeting, we are pressed for time, so it would be helpful if our witnesses could keep their answers concise.

Willie Coffey has some questions in this area, so I invite him to come in.

I want to follow up on Craig Hoy’s question about funding and sustainability.

If you look at the figures that the Auditor General presented to us on adult social care spend, you can see significant increases in the spend over the past 10 years—in fact, it has gone up by 22 per cent. Caroline Lamb said a moment ago that we plan to spend another 25 per cent more. The bottom-line question for me is whether the additional funding and the whole-service redesign that is coming through the national care service will be adequate to address the concerns that the Auditor General expressed about the future sustainability of the service. Could you give us your view on that, Caroline, and some reassurance, if you can?

The additional funding that we have already made available in the system is making a difference, and the commitment over this parliamentary session is important. We still have more work to do to understand the nature of the demand and whether we are addressing that demand at the most appropriate point. Are we providing support to people early enough to prevent them from needing more support because they were unable to access the support that they needed earlier?

We are still understanding the impact of the pandemic on some parts of society—for example, the extent to which the inability of the elderly population to get out and do the things that they would normally do has had a detrimental impact. We need to understand how we can assess that and meet that demand in future.

The answer to your question is that we still have work to do to bottom out what we expect in terms of demand and to start to do scenario planning on that.

That will do for now, convener. I know that we are pressed for time.

Service users and carers do not always have a say in or choice about what support works best for them. Self-directed support was designed to give people choice and control over their care, including personalised options for carers to take short breaks from caring. SDS has not yet been fully implemented. People using social care support have described the hurdles that they encounter in accessing services and support as a battle, difficult, overcomplicated and bureaucratic. The pandemic has highlighted the precarious situation of many vulnerable people who rely on social care or support, and it had a negative impact on people who require support. The Scottish Human Rights Commission has expressed deep concern about the level of social care support that is likely to be available in future to people whose packages were reduced or withdrawn during the pandemic. How is the Scottish Government involving service users and carers in reforming social care services?

In my opening remarks, I talked about how conversations with people with lived experience are already influencing our review of self-directed support. I will ask Donna Bell to say a bit more on that, and Nicola Dickie might want to say something about consistency of implementation.

Earlier, I mentioned the work that we are doing to revisit the self-directed support guidance. We are clear that, although it is necessary, guidance alone is not sufficient for making the change that we need to see in self-directed support. There is an implementation gap—we are all clear about that. We are working with a fairly broad group that includes people with lived experience and people who have caring responsibilities to agree a way forward for improvement.

We have had two short-life working groups meeting as part of that review, and a number of key themes have been identified that are concurrent with what the member has highlighted. There is work to do on effective and consistent decision making, and on considering whether there is any conflict in the legislation and policies. We also support the support in the right direction programme, which provides support and advocacy. We are keen to draw all that together and put in place a set of improvement actions to ensure that there is much more consistency, that access is more streamlined and that people can get what they need from self-directed support.

I concur absolutely with what Donna Bell just said about the voice of lived experience coming through. The minister has also established a social covenant group, in which service users provide their opinions directly on current social care provision and on the reforms that are coming. COSLA’s health and social care spokesperson, Councillor Stuart Currie, sits on that group, so, at a political level, he is hearing directly from service users, which is good.

During the pandemic, Donna Bell and I chaired the pandemic response in adult social care group. On that group, we had unpaid carers’ representatives and carers associations and other people who represented service users. We are getting better, but there is always more to do.

I also point out that local government hears from users of social care every single day, in every community the length and breadth of the country. I am sure that if there were a local councillor here today, they would tell you that they get a lot of experience and feedback, as I am sure members of the committee do.

I come back to the point about localisation and unmet need. We have to be absolutely clear about the difference between outcomes and what people actually access and experience. COSLA is an avid believer that, although the access to support that someone gets in Shetland and the process should be the same as they are elsewhere, the actual outcome might be different, because the way in which people get support with social care needs in Shetland might well be very different from how people are supported in the centre of Glasgow. I think that we can agree that that is true, because people are individuals.

That goes back to the point that I made in my opening remarks. We need to ensure that we are seeing person-centred outcomes, and we need to get away from the idea that a national model will support individualised outcomes. Such a model might well support similar outcomes, and we have worked hard through the process of—[Inaudible.]—one size fits all.

I will not sit here and say that it is all perfect, because it is not. We have already alluded to the demographic and financial challenges that we face in Scotland. We also need to think about the fact that the pandemic did not hit all our communities equally at the same time. During the pandemic, we heard comments such as, “Why are day services still closed in X authority when they are open in Y authority?” The pandemic was not being felt in the same way across our cities as it was in some of our rural areas.

We need to be careful that we do not strive for a one-size-fits-all approach and move away from what we have been talking about for a very long time, since Campbell Christie’s commission, which is prevention and person-centred outcomes. From a local government perspective, COSLA has approached the independent review and the Scottish Government consultation by saying not that everyone should get the same outcomes, but that, while everyone should get the same support and go through the same journey, ultimately the outcomes might not be the same—[Inaudible.].

The pandemic also put additional pressures on unpaid carers, because of the closure of day centres and respite services, and that resulted in increased feelings of anxiety, depression and mental exhaustion. Have all those facilities opened up again since the pandemic? If they have not, what is the Scottish Government doing to ensure that they are opened to give people the support that they need?

Nicola Dickie might want to come in on that.

09:45  

I cannot speak for the Scottish Government, but from a local government perspective we recognise that the closure of the centres at the very height of the pandemic, in the early days, was done on the basis of public health guidance. We did not want people who were vulnerable or—to use the term that was coined at the time—shielding to be put into centres where they might have increased exposure to the virus.

We have to remember that there was a public health reason for day centres being closed. From a local government and a health and social care partnership perspective, we absolutely recognise the importance of getting those day centres back up and running for people if they want them. To go back to my earlier point, when the day centres were closed, local government, along with our partners, tried to step into the space and take a person-centred approach to what might work for those individuals who had previously been in day centres.

For obvious reasons, there was some nervousness about a service worker coming in and people accessing support in their own homes when they were shielding, instead of going to a day centre. When the day centres closed, there was an element of trying to step in and provide support, but there was a bit of reticence in some respects and there were also workforce challenges for local government. During the pandemic, the way that we approached the issue of day centres changed, not always for the same reasons. Very early on, some of the changes were based on public health advice that day centres were high-risk settings and should not necessarily be operating.

As we have come through the pandemic, those day services, where there is still a requirement for them and where that is what local service users want, have reopened. In some areas, local government has taken the opportunity to reform the services. We have moved a wee—[Inaudible.]—as people have moved in to other things.

To go back to my point about localisation, it is difficult when we say that a service that dealt with 150 people before the pandemic deals with only 140 now. That might not always be a bad thing, because people might have gone elsewhere or started to access different support. That might be exactly where we want them to be. To go back to the point about choice and responsibility in personal support, that might be a good thing.

Donna Bell might want to talk about the Scottish Government’s approach to day services.

Nicola Dickie has covered most of it. I simply say that we have worked closely with Public Health Scotland and others to ensure that the guidance is right and that folk are supported to open up services as and when they can. Last year, Kevin Stewart, the Minister for Mental Wellbeing and Social Care, wrote to encourage day centres to reopen. I think that Nicola Dickie has covered the primary points on localisation.

Sharon Dowey asked about commissioning. I would like to ask Caroline Lamb, who is the chief executive of NHS Scotland as well as the director general of health and social care, about the commissioning model, which is not the model for the national health service, is it? Arguably, there would be an outcry if we went down that route as the model for delivering NHS services.

As part of your discussions with COSLA, and looking to the national care service of the future, are you looking at alternatives to a competitive tendering model, which is how the commissioning model has developed?

A key point is that, among the independent review recommendations, there was a recommendation, which is also part of the joint statement of intent with COSLA, to move towards ethical commissioning. That is much more about a partnership approach to commissioning and a focus on the outcomes and what is important to people. We have started the process of engaging in draft ethical standards. Donna Bell can say more on that.

In preparation for moving towards the recommendations from the independent review, we also issued a Scottish procurement policy notice in December. It was designed with key stakeholders and advised people of the actions that they can already take in commissioning and procurement, as well as how we can make improvements on that.

I ask Donna Bell to comment on some of the detail of the work on ethical commissioning.

The procurement guidance that was issued in December is an important starting point, because a lot can be done to bring current activity in line with the principles of ethical commissioning.

There is a lot of work to do. We have had some great input from the Coalition of Care and Support Providers in Scotland and others on where we might go with it. It is not straightforward, so there is a significant amount of work to do, which will take a bit of time. However, a focus on what can be done now is important. Colleagues in local government have been working closely with us on what can be done now, so it might also be worth asking them to comment on it.

Sarah Watters wants to come in, so I invite her to comment on that.

My comment is not specifically about Donna Bell’s point but about ethical commissioning.

Local government takes its commissioning across a range of services seriously. As well as ethical commissioning, there is sustainable commissioning and local commissioning. Many councils are working on community wealth building strategies.

Ethical commissioning is only one part of what local government does. We try to ensure that we get the best value for local communities right through the commissioning process. However, as the Auditor General said, with single-year budgets, that is really challenging because you always have to have one eye on what you will need to do next year and the year after.

Ethical commissioning is just one of a range of commissioning approaches that councils are trying to take.

In those answers, I did not hear anybody talk about going beyond commissioning or about conversion to more of a national health service model for the national care service. However, we are pressed for time, so I will move on.

We have covered a lot on the workforce, but I have a parting question on that. Caroline Lamb, you mentioned the uprating of the hourly rate of pay from April this year. Do you have a timetable showing where you expect rates of pay to go in the next five years? That is the time horizon that you spoke about for the 25 per cent uplift in resources.

No. Pay will be one factor of the 25 per cent uplift, but we have not yet modelled exactly what that will look like.

That is fine. That is clear.

Leadership in the public sector is a concern that has been raised depressingly often. In this case, I draw the witnesses’ attention to paragraph 20 of the Auditor General’s briefing, which says:

“The health and social care sector needs stable and collaborative leadership to address the … challenges”.

There is also reference to the local government overview of 2020, which

“emphasised the critical need for effective leadership”,

which was absent. Also, the “NHS in Scotland 2020” report

“highlighted the continuing lack of stable NHS senior leadership, with high turnover and short-term posts.”

Those are serious issues. Leadership is vital but we often find that it is absent. We are considering the challenges that face social care, which seems to face exactly the same issues with leadership. Perhaps Caroline Lamb might comment on that and how it is being tackled.

Yes, I am happy to respond to that, and I am sure that colleagues will also wish to contribute.

I agree that the health and social care sector needs stable and collaborative leadership. That is not necessarily always about everybody staying in the same job. We see real benefits from people moving between health and social care, and we have examples of chief officers who have become chief executives of NHS boards. That helps to break down some of the barriers and can enhance the collective understanding of some of the challenges across the end-to-end system.

However, the pandemic put the workforce and our senior leaders under extreme pressure during the past couple of years. People have worked incredibly hard in the face of some extraordinary challenges. That said, the pandemic was also a unifying factor: it brought people together. Most of the people whom I have spoken to around the country commented positively on how the experience of Covid and of working together with clear priorities brought them together into a collaborative space, building relationships that are stronger than they were before, and I think that that will endure.

We need to remember, however, that collaborative leadership becomes more complex as priorities become more complex. [Interruption.] Excuse me. There is a risk of the focus and the single mission that we had throughout Covid getting a bit diluted.

I am sorry, but I am choking a bit, so I will pass to Donna Bell now, and she can perhaps talk you through some of the things that we are doing to support leaders and leadership across the system.

We work very closely with chief officers in particular. Support is offered to them, although they are a very good self-supporting network, which has led to some great connections and practice sharing. There is a good leadership cadre there, and they support one another. There is activity in place to support wellbeing, leadership coaching and various other aspects.

Caroline Lamb made an important point about collaboration and people learning together and addressing joint challenges. As Caroline says, learning and collaborating on the job during the past few years has brought people much more closely together in understanding their common challenges.

The focus on wellbeing is important. As Caroline Lamb says, it has been a very difficult time for much of the leadership in health and social care; it has challenged people and helped them to grow in their roles. As we come out of the current period, there will be more to do, but there is a fair amount of support in place already.

Nicola Dickie might want to talk a wee bit about local government and any specific measures that are in place there.

There is something I wish to point out before Nicola Dickie comes in. The Auditor General’s briefing is dated January 2022. I applaud the optimism in everything that the witnesses are expressing about collaborative work, but that is not being evidenced in what is coming before the committee. It will obviously take time before that work feeds through but, based on the evidence that the committee has seen, it is substandard, to be honest.

I absolutely agree with what Caroline Lamb and Donna Bell have said about Covid bringing leaders together. COSLA’s submission, and indeed that from the Society of Local Authority Chief Executives and Senior Managers, the chief execs’ core submission to the Scottish Government consultation on the national care service, flagged up the risk of destabilising the senior leadership within health and social care and the wider public sector. That is a risk, and it is one that people are aware of.

There is an awful lot of support going to all Scotland’s public sector leaders for leading through change. There is not a single part of the public sector in Scotland—social care included—that will not be going through some form of change as we come out of the pandemic.

The Scottish Leaders Forum has been set up and we have the various support networks there, but chief executives in local government and, I am sure, although I do not speak for them, chief executives in the NHS are mindful of that. Do we have the silver bullet at the moment? I do not know, but it is certainly on the risk list from a local government perspective to ensure that senior leadership across local government and the wider public sector are supported regardless of whatever the form of the national care service might be.

10:00  

Very briefly, because I am conscious of time, paragraph 21 of the briefing refers to the issues between partner organisations and the model of governance being overcomplicated. That is not new; those integration authorities have been in place for some time. Donna Bell said that we have been learning from other integration initiatives by the police and so on. Again, I say that there seems to be very little evidence of that coming through in the Auditor General’s briefing as at January 2022, when the briefing was produced. I am hearing a lot of good words, but I do not see the evidence, although I hope that we will see it in the future. Does anyone want to say anything further on the integration authorities?

I think that Donna Bell wanted to come in and I would like to give a specific example of collaboration.

The first reference that I made to understanding change and the need for change was to integration authorities. We know that Audit Scotland has published a number of reports on learning from integration and we have a range of our own learning. I absolutely recognise what the member says about the need for change, and that has come to fruition through the independent review of adult social care and the proposals for the national care service. Those things and all the other work that is under way are a direct response to the points that the member makes. It is absolutely the case that we are learning from where we are now, and we are putting plans in place to address the issues that have been identified.

That ends the committee’s questions. I thank Caroline Lamb and Donna Bell from the Scottish Government and Nicola Dickie, who may have dropped off—if she can hear us, I hope that she takes our thanks for her evidence—and Sarah Watters from COSLA. We will reflect on the evidence that we have taken and decide on our next steps. Thank you for your co-operation and I hope to see you again soon.

I now suspend the meeting to allow for a changeover of witnesses.

10:03 Meeting suspended.  

10:04 On resuming—