Good afternoon, everyone. The first item of business this afternoon is a statement by the Cabinet Secretary for Health and Wellbeing, Alex Neil, on care and caring. The cabinet secretary will take questions at the end of his statement, so there should be no interventions or interruptions.
One of the key functions of government is the care that it provides, funds, supports, encourages and regulates. Care and caring touch every family in our nation. Today, I will update the Parliament on the next steps in developing our longer-term strategy for care services and support in relation to integration, the national care standards, residential care, intermediate care and continuing care.
The Public Bodies (Joint Working) (Scotland) Act 2014 received royal assent last month. I am pleased to tell the Parliament that we will begin consultation on the first substantial set of accompanying regulations on 12 May and that consultation on the second set will begin before the end of May.
The regulations will underpin the operation of health and social care integration across Scotland, including the prescription of the integration scheme; the functions that local authorities must delegate; the functions that health boards may or must delegate; and the national health and wellbeing outcomes. I encourage everyone with an interest to respond to the consultations, which will run through to August.
However, it is not enough simply to improve the organisational and operational structure of care services; we must also continue to develop the standards of the care that is provided. The national care standards were created in 2002 to help people who benefit from care services to understand what to expect from services and to help service providers to understand the standards that they are expected to achieve.
In the 12 years since the standards were introduced, a great deal has changed in how care services are delivered, and there will be changes in the future—not least from the 2014 act. To keep pace with those changes, we will begin consulting on new national care standards at the end of May. We want not only to underpin the quality of care but to improve fairness. We want everyone in Scotland to receive a high level of care, no matter what service they use or where they live.
A robust inspection regime is key to improving standards. The Care Inspectorate is undertaking a wide-ranging review of its inspection methodology during 2014. The review will align closely with the review of the national care standards and will ensure that inspection focuses on assessing how well services respect the rights of people who use them and promote positive outcomes.
The Care Inspectorate and Healthcare Improvement Scotland are developing a new model for the inspection of integrated care for adults, beginning with older people. The new model, which looks at how well health and care systems work together to deliver improved outcomes, will include scrutiny of health board and local authority joint commissioning plans.
We have worked with our partners in the Convention of Scottish Local Authorities to examine the future of residential care. Our joint task force report on the subject was published earlier this year and it provides a useful foundation for developing that vital area of the care sector. The task force considered and made recommendations on a number of aspects of residential care, not least increasing personalisation; planning for the kinds of environment that we want to deliver care services in; and considering how we commission those services, how we align our workforce resources to deliver them and, of course, how we pay for them.
The report recommends further work on how the living wage could be applied across the care sector. We have already implemented the living wage for all Scottish Government and national health service staff and, with our partners in COSLA, for local government staff. We are looking for new ways to encourage and facilitate the adoption of the living wage across the entire care sector.
The Scottish Government accepts in principle the report’s main recommendations. We will work in close partnership with COSLA and other key partners to take forward its recommendation to develop a strategy for the long-term transformation of residential care, supported housing, co-housing, and intermediate care.
Having worked constructively with the task force’s members, we will also engage with those key stakeholders to look at personal care services that are provided to people under 65 who have complex needs and to examine whether those people are receiving effective support. That issue was most effectively highlighted to me by Mrs Amanda Kopel, the wife of the late Frank Kopel. I am committed to examining the current provision carefully.
Although there is clear understanding of the role of acute and primary care, more must be done to develop intermediate care services across Scotland. Intermediate care provides a bridge between hospital and home. It helps people to move from illness and injury to recovery and independence. Those step-up, step-down services provide a period of intensive support and rehabilitation at home or in a community setting and give people the opportunity to fully recover, build confidence and independence, and, it is hoped, remain at or return home. Strengthening intermediate care, not least in the provision of rehabilitative care for elderly people as they leave hospital, is critical. That is just one of the ways to improve flow through hospitals, which is a key issue that is highlighted in the report on accident and emergency departments that was published today by Audit Scotland.
This week, I have written to all territorial health boards and local authorities to identify the areas in which further support is needed to enhance intermediate care services. That work will include informing the on-going development of the bed planning tool and long-term national health service care provision.
Last week, the expert “Independent Review of NHS Continuing Care” report was published. Before I move on to the review’s recommendations, I should say that we have been clear that, if anyone has been incorrectly charged under the current regime, they should be appropriately reimbursed. We want to ensure that no one ends up in that position. I understand that a small number of appeals to health boards are being processed. I encourage boards to bring them to a conclusion as quickly as possible.
The review, which was chaired by Dr Ian Anderson, who is a past president of the Royal College of Physicians and Surgeons of Glasgow, assessed the current guidance and its implementation across the country. I am grateful for Dr Anderson’s work and accept the group’s recommendations on the future of NHS continuing healthcare in Scotland, but there are two points that I wish to make clear in qualification.
First, patients who are being treated as part of the proposed continuing care programme will remain in hospital only for as long as that is clinically necessary. Any patient who does not require care in a hospital setting will be discharged from hospital into the community in line with our 2020 vision for treating people at home in the community in a homely setting. Patient safety and the quality of care will be the overriding concerns.
Secondly, any changes to the current policy will come into effect only when new guidance is consulted on and developed. We expect that that will be in April 2015. That means that the current guidance on continuing care remains in place and any patient who is clinically assessed as requiring that form of care must receive it. Any patient who is currently in receipt of NHS continuing care in a care home or who is assessed as requiring continuing care before new guidance is put in place will continue to receive the same level of financial support that they would today. No patient will suffer financial loss resulting from the implementation of Dr Anderson’s recommendations.
Through Dr Anderson’s group’s recommendations, we will work with NHS boards and COSLA to develop new guidance for the operation of NHS continuing care that puts patient quality and safety to the fore. New guidance will be developed in parallel with on-going developments in intermediate care to inform how services are designed, and the particular challenges that face rural communities in that regard will be specifically addressed.
Through self-directed support, we are empowering disabled and older people to take control of their own care. Self-directed support is delivering transformational change to the social care sector and we will continue to support its implementation.
As well as the care that is provided by local authorities, the NHS and other public services, unpaid carers are another vital community who are key to the provision of care in this country. Those people care for the ones they love, sometimes to the detriment of their own health and wellbeing. They need our support and commitment. Since 2007, we have invested £113 million in vital support for unpaid carers and young carers in Scotland. Our programmes and initiatives cover a range of support, including short breaks, information and advice, advocacy, training, income maximisation services and education. We are supporting carers and young carers to continue to care for their families, friends and neighbours, and—most important—to have a life for themselves alongside their caring role.
However, we believe that there are still inconsistencies in how that support is provided. We intend to introduce legislation during this session to address that and ensure that all carers and young carers in Scotland receive the support that they need. Our consultation on that proposal closed last month. We aim to issue our formal response to the views expressed this autumn. Our aim is simply to enhance the support that is provided to carers and to address the whole carer journey.
The Parliament can be rightly proud of introducing free personal and nursing care for the elderly, and I reiterate the Government’s commitment to such a vital policy. The introduction of the policy highlighted that, when it comes to planning the care that we as a Parliament wish to provide, a key part is outwith our control: the operation of the welfare system.
The people of Scotland are already disadvantaged by a Westminster Government that refuses to pay attendance allowance to Scots who are in receipt of free personal care. Scotland can make its resources work better for the people who live here by having a co-ordinated approach to the delivery of benefits and related services, such as health and social care, so that that type of loss does not happen. Having control over our welfare system will enable us to work with interested parties to make sure that the benefit system and the application of free personal and nursing care are properly integrated.
I firmly believe that a genuinely person-centred approach that sees care provided in the most appropriate setting, whether that be a community, primary, intermediate or acute setting, will ensure that everyone who provides or receives care or caring is provided with the respect and service that every person deserves.
The cabinet secretary will now take questions on the issues raised in his statement. I intend to allow approximately 20 minutes for questions, after which we will move on to the next item of business.
Care and care-related issues are among the greatest challenges that face the health and social care sector. People continually tell me that the system is in crisis, and that that crisis ripples throughout the healthcare system.
Scottish Labour supports the moves to improve the inspection regime, standards, and the rights of and support provided for carers. We call on the Scottish Government to hold a debate in Government time so that we can debate in depth all those crucial matters. It would also allow us to pay appropriate tribute to Amanda Kopel for her fantastic campaign and her humanity and caring for others.
It is my understanding that the review report on NHS continuing healthcare has been sitting on the cabinet secretary’s desk for months, only to be sneaked out quietly at the start of the bank holiday weekend so that no one would notice. In his statement, he failed to mention the fundamental point that, if adopted, the change in policy will see patients being charged for their primary healthcare needs when that would previously have been paid for by the state. The cabinet secretary could not quite bring himself to tell members that this afternoon.
Patients who have conditions such as motor neurone disease, whose patient association was not consulted on the matter, have been told that they will now have to pay for elements of their on-going treatment when previously the state paid costs that can average more than £700 a week. Families are facing a perverse incentive to try to ensure that their loved ones remain in hospital to avoid crippling charges. All of that is happening within a system that, it is proposed, will have no national guidelines and no independent appeal process.
The recommendations in the report are a fundamental breach of the guiding principle of the NHS, which is that it should be free at the point of need. The report is flawed and, having taken advice, I believe that the proposals may be illegal. Has the cabinet secretary taken his own legal advice on his charging plans? What consultation has there been with patients and families? Does the cabinet secretary accept that, for those who are affected by the charges, the NHS will no longer be free at the point of need?
I will concentrate on continuing care. Let me make this absolutely clear. Neil Findlay says that the recommendation of the report—and our policy—is to charge for primary healthcare needs. That is absolute bunkum of the first order. Every part of healthcare in Scotland will remain free even when the new guidelines are published. I said nothing in my statement that could be interpreted as saying that primary healthcare needs will be charged for. People who are living in nursing homes, receiving care at home or in hospital have any healthcare needs met free of charge in addition to their free nursing and personal care. The idea that we would charge for primary healthcare needs is totally absurd. That is not recommended in the Anderson report and it is certainly not the policy of this Government.
Furthermore, Neil Findlay says that there will be no national guidelines. I specifically said in the statement that we will consult on and develop national guidelines. How can he reach the conclusion that there will be no national guidelines? He also said that there will be no appeals system. Of course there will be an appeals system. The creation of such a system will form part of the consideration of the national guidelines. When questions are asked and interpretations are made, could Opposition spokespeople on the Labour side please stick to the facts instead of inventing pure nonsense?
I thank the cabinet secretary for advance sight of the statement.
The report deals with some fairly fundamental issues in considerable depth and there is considerable analysis—much of which we agree with. However, I think that there is ambiguity in public understanding of the recommendations in relation to continuing care, and I do not think that those are wholly politically mendacious. A considerable number of organisations have contacted Parliament since the announcement was made and have concluded—as did Neil Findlay—that there is an intention to charge for non-hospitalised care.
I hear what the cabinet secretary has said, and I hope that there can be a debate in which the issues are properly teased out and discussed, but it would be very helpful for him to correct the ambiguity in the public mind and undertake to work with the other parties, because we want the widest possible consensus to underpin any regulations, conditions or appeals process that might subsequently follow.
Jackson Carlaw, as always, makes a very reasonable point in a very reasonable tone. Let me reiterate that there is no proposal—there was no such proposal in the report and it certainly is not Government policy—to in any way charge for healthcare at all. I think that where people are getting confused is that, when people who are currently under the existing regime of complex continuing care are in an NHS bed in a care home, in addition to free personal care they have their accommodation costs paid. I think that the misinterpretation has been around accommodation costs.
I have made two things absolutely clear. First, in the meantime—pending the development of future guidelines and so on—those costs will continue to be met both for existing patients and for any patients coming into that system. I am more than happy to sit down with all the parties in the Parliament as part of the consultation process and, ideally, try to reach a consensus on the way forward. It is better if we can achieve consensus on these matters, because that means that in future there will be stability in the system and people can have confidence that they know what kind of support to expect, both financially and in other respects, and when to expect it.
Let me categorically make it clear that at no stage, either before or after 2015, will there be a system of charging for healthcare needs in Scotland, no matter whether somebody is being treated in hospital, at home or in a nursing home.
The cabinet secretary might have seen that the number of hours of personal care that are being provided in Aberdeen city dropped in the past year, and that there has been an increase in delayed discharge in the city, as many people have been unable to access appropriate care packages that would enable them to return home. Indeed, the cabinet secretary heard some of the concerns when he visited the Danestone medical practice in my constituency.
Given that Aberdeen City Council has sought to externalise its care function to an arm’s-length company, with minimal scrutiny from elected members, will the cabinet secretary advise me what steps he can take to ensure that the council is reminded of its responsibilities and obligations to our most vulnerable citizens?
I am aware of those concerns. Problems are created by the establishment of an arm’s-length executive organisation—Bon Accord Care in this case—to run the services, particularly at a time when the whole thrust of policy, as agreed by all members of this Parliament, is the integration of services. To semi-privatise services in the way that it looks like Aberdeen City Council is trying to do is about the disintegration, instead of the integration, of services.
I am very much aware of the delayed discharges issue. If we analyse Grampian NHS Board’s delayed discharge figures, we find that there is no fundamental or major problem in rural Aberdeenshire and that the problem is very much confined to the city of Aberdeen. Much of that is because of the lack of social care provision in the city of Aberdeen, whether it is assessment provision or care home provision. Therefore, I am keen to work with the council, as is Grampian Health Board, to try to resolve those issues, because the people of the city of Aberdeen require it. However, at a time when we are integrating services, it was perhaps not the wisest thing to do to hand services out to an ALEO.
The cabinet secretary says that he is looking for ways to adopt the living wage throughout the care sector. That is a key recommendation of the report, “The Future of Residential Care for Older People in Scotland”. If he is serious about improving the quality of care provided to the most vulnerable in our society, he must value those who deliver that care. I ask him therefore whether he will back Labour’s amendment to the Procurement Reform (Scotland) Bill next week to make that aspiration a reality.
I am no longer in charge of the Procurement Reform (Scotland) Bill, which is now the responsibility of my colleague Nicola Sturgeon. Once I have seen the Labour amendment, I will take Nicola Sturgeon’s advice on whether to back it. We operate as a team, with collective responsibility.
There is no doubt in my mind that the introduction of the living wage throughout the sector would be an extremely helpful part of the drive that we and COSLA are engaged in to improve the quality of social care in Scotland. We are engaged in an exercise with COSLA on how we take forward that proposal, and other proposals, all of which are part of a package to revolutionise the quality of social care in Scotland.
The cabinet secretary referred in his statement to the case of my constituent Frank Kopel. I thank him for the way in which he engaged personally with Mr and Mrs Kopel, including visiting Frank in Kirriemuir a few weeks before, sadly, he passed away.
I very much welcome the cabinet secretary’s commitment to examine the present provision of personal care services for under 65s with complex needs. Is he able to offer further detail on how that work will be progressed? Will he ensure that the real-life experience of people such as the Kopels will be at the centre of that consideration so that any changes that are ultimately forthcoming match the needs of those requiring support?
Amanda Kopel has brought to the Parliament’s notice, as well as to mine, the issue of dementia affecting people under 65. There are 3,000 dementia sufferers in Scotland who are under 65. They do not currently qualify for free personal care. There will be people with other ailments in a similar position.
When free personal care was introduced, it was for the elderly population. The rationale for that was that the welfare system—in particular, benefits such as the disability living allowance that we have now—was supposed to cover the costs associated with disability and therefore any additional costs that someone has. That is why, when free personal care was introduced by Henry McLeish, as First Minister, it did not apply to under 65s.
The issue that Mrs Kopel has raised is that some people, such as the late Frank Kopel and herself, fall between two stools. The Kopels did not receive benefits that would have covered any care home or other costs, and when Frank Kopel was diagnosed with Alzheimer’s he was not old enough to qualify for free personal care. We have a duty to look at whether that is a major problem and, if it is a problem of scale, how we should address it. That is why I referred to the welfare system in my statement. In issues such as this, the interplay between the welfare and benefits system and the health service is crucial.
The cabinet secretary has made it as clear as mud regarding whether continuing care is free and whether it covers accommodation.
That aside, is the cabinet secretary aware that there is a lot of dissatisfaction among carers about the discharge from hospital of those they care for and the lack of consultation that takes place with clinicians? That poor communication leads to poor discharge planning and can ultimately lead to patients being readmitted when the necessary support in the community is not ready. What plans does the Scottish Government have to introduce a duty on health boards to inform carers fully of hospital admissions and discharges? Will he ensure that that forms a key part of carers legislation?
Most of the delayed discharge issues that people write to me about concern the delay itself. There is very often no assessment and no care home facility available for the patient to go to, which is why the step-down facilities are so crucial.
I have never received any representations about a lack of consultation on the discharge process itself. If Jim Hume wants to provide me with the evidence that that is an issue, I will certainly take it up not only with the NHS but with the relevant royal colleges.
Can the cabinet secretary update members on the current state of development of the bed planning tool, which will help to ensure that our hospitals and communities have the necessary capacity with the right type and number of beds in the right specialities and in the right place for local populations, and say when the tool will be in full operation?
Yes. The aim of the bed planning toolkit is to provide mandatory guidance on the key steps that all NHS boards should follow in planning bed capacity. The Scottish partnership forum, the national strategic group on joint commissioning and the unscheduled care programme board—we are not short of bodies in the national health service—are engaging with the Scottish Government on the development of the toolkit.
In developing the toolkit, we are considering current NHS Scotland bed planning practice as well as practice in other countries. We plan to engage widely over the summer, and the toolkit will be made available to all NHS boards by the end of the year.
I draw members’ attention to my interest as a director of a small nursing home in England.
Does the cabinet secretary really support recommendations 2 and 7 in the report? I find them astonishing, and a recipe for future postcode problems. They return us to an era in which clinicians make decisions, with
“No ... eligibility criteria, or scoring system”;
it is only the doctor and the team who decide whether someone requires hospital care.
Moreover, at recommendation 7 that is backed by an appeal system in which a single doctor decides—there is nothing about any consultation with patient representative groups. Those recommendations return us to a previous era from which I thought that we had moved away.
Furthermore, that undermines the cabinet secretary’s earlier report on care homes, which stated that care homes should cope with:
“Tracheostomy Care; Percutaneous Endoscopic Gastrotomy (PEG) feeding; Delivery of IV Fluids and/or IV Antibiotics.”
Those aspects are usually part of hospital care, and I am concerned that, without criteria, we will have a complete mess. The report is frankly very poor.
I disagree with Dr Simpson’s last point, but I fully accept that there is a need for guidance on all those issues. I said that I welcomed the report in principle and the general thrust of the recommendations, but there are consequences arising from those recommendations that require further consideration. I am happy to consult other parties on how we move forward on those issues, because I want to get this right. That is a very good example of where the devil is in the detail.
I would particularly welcome the expertise of Dr Simpson, who has lengthy experience of such matters. Before we decide on, develop and publish the resulting guidance, we will consult widely. We are not implementing anything before April 2015, because I want to be absolutely sure that we get it right.
I am open to concrete and positive suggestions from Dr Simpson—and even from Mr Findlay, although I have never heard any such suggestions from him—and from other members in the chamber. I look forward to that consultation.
I note that the Care Inspectorate is undertaking a review of its own methodology. I refer to my concerns about the current assessment methods in the context of the report that I am holding up, which is on St Ronans care home in Innerleithen.
The report states that:
“Quality of Care and Support”
for the residents is
“Weak”.
At a meeting on Sunday of nine relatives at the care home, every single one made clear that the assessment in no way reflected their experience of the care that their elderly relatives had received. Does the cabinet secretary feel that it is sufficient for the Care Inspectorate to review—or indeed inspect—itself?
Without being able to comment on any individual case, I accept as a general principle that, where there is genuine, strongly held disagreement about a draft report, there is a need on certain occasions and using certain criteria to have a degree of arbitration, particularly where there is a challenge to the factual accuracy of a draft report by the Care Inspectorate.
I am already discussing the matters to which Christine Grahame referred with the board, the chair and the chief executive of the Care Inspectorate. We have a meeting coming up fairly soon to discuss the issue with residential care home owners and the Care Inspectorate to see whether we can reach an accommodation that is appropriate while ensuring that the integrity of the Care Inspectorate’s inspections is in no way compromised. I am more than happy to invite Christine Grahame’s constituent to that meeting.
I welcome the cabinet secretary’s statement as it reflects much of the work that has exercised the Health and Sport Committee over the past years. I am pleased that we will finally consult on a new set of national care standards, although I have to express some disappointment that it has taken so long, given that the committee recommended such action in 2011 and that the cabinet secretary’s predecessor said in the chamber in June 2012 that a consultation would begin in the summer. Given that disappointing delay, can we have a firm guarantee from the cabinet secretary that we will have a full public consultation and not a consultation on a consultation? Can he assure us that the Government will be in a position to announce a new set of national care standards by the end of this parliamentary session?
First, I congratulate Duncan McNeil as convener of the Health and Sport Committee on the tremendous work that the committee has done in this area. As well as consulting other parties in the chamber, I will of course be very keen to consult the committee on how we take the agenda forward, as I know that the committee is very interested in that.
I give a very firm undertaking to Duncan McNeil that the consultation that we will launch will not be a consultation on a consultation but the only consultation. However, I think that delay in this case has been a benefit, because we now have legislation on integration. Of course, one of the challenges for the new integrated framework in the future will be to reconcile the needs of clinical guidance with the national care standards. In taking forward the consultation, I am very conscious that, as we are providing integrated services, there needs to be an alignment between national care standards and clinical guidelines and, indeed, other protocols, too. I therefore think that the timing might, in fact, have been quite good, although I admit that that was not done by design.
I welcome the cabinet secretary’s comments on the adoption of the living wage across the care sector. Can he confirm that, in any consideration of intermediate or continuing care, the special problems of rural Scotland will be taken into account?
I specifically mentioned rural Scotland in my statement because I am very well aware of the issues facing remote and rural communities and, indeed, island communities. There are particular challenges in island communities that are not just about being remote and rural. When we are commissioning care services—this will be part of the commissioning plans that are being drafted as we speak and which will be consulted on by the shadow boards—it is very important for our rural, remote rural, and island communities that the commissioning plans fit well with the needs and aspirations of all those communities.
Obviously, there are particular challenges in the remoter and more difficult to access communities. The role of telehealth and telecare is extremely important in that regard. That is why we are working with the Scottish Centre for Telehealth and Telecare to develop and increase the use of techniques such as videoconferencing and remote monitoring and management of care. Indeed, we have earmarked £10 million for such projects, which will be of particular benefit to rural, remote rural and island communities.
The reason why primary care needs were referred to is that that is the wording in the National Health Service (Scotland) Act 1978 and the National Health Service Act 1977. I am sure that the cabinet secretary realises that the judgment in England that someone with primary care needs in a nursing home should have all their costs met was in relation to the 1977 act. Has he taken legal advice on this? Given that there is a lack of clarity in his statement, will he confirm that anyone with primary care needs in a nursing home will have all their costs met, including their accommodation costs?
I reiterate that it is the case today and it will remain the case that anyone with primary healthcare needs will have those needs met by the national health service, irrespective of whether that is in a hospital setting, a nursing residential setting, at home, in a hospice or in many other areas. That is our position today and it will continue to be our position. Healthcare in Scotland is free at the point of use and it will remain free at the point of use.
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