Meeting of the Parliament

Meeting date: Wednesday, November 14, 2018

Official Report 1048KB pdf

---

Social Care

As I said, we lose time even at a changeover, so I am afraid that I am going to move straight on. I think that Mr Rowley is ready.

The next item of business is a debate on motion S5M-14717, in the name of Alex Rowley, on investing in social care for Scotland’s future. I call Mr Rowley to speak to and move the motion—eight minutes, please.

14:40  

Labour lodged the motion for debate today in order to highlight what we see as some of the challenges that are faced by providers of health and social care. We have always been supportive of the integration of health and social care services and the setting up of the integration joint boards, while being clear that community care must never be seen as care on the cheap and therefore must be funded to ensure the highest level of quality and support to meet individuals’ needs.

Age Scotland states that a lack of social care has a direct impact on other vital services, such as the national health service. In September 2018, figures showed that four in 10 people who were ready to leave hospital waited more than a month to do so. That represents too many older people at risk of losing their mobility and independence, which puts their health and wellbeing at risk. Age Scotland also states that the Scottish Government must urgently take action to reduce that figure and ensure that health and social care is adequately funded for every older person who needs it.

The Labour leader of the Convention of Scottish Local Authorities, Councillor David Ross of Fife Council, has called on the Government to recognise the key role that social care plays in the health system and provide additional funding to support that. He states:

“If spending on the NHS continues to be protected, then so should social care spending.”

He continues:

“Expecting the NHS to transfer adequate funding into social care from acute lacks transparency and is unrealistic.”

He goes on to say:

“There is concern that in the past, additional funding for social care has been channelled through the NHS and some of this has been creamed off before reaching social care services.”

There needs to be more transparency around funding for health and social care.

I am sure that Mr Rowley will recognise that I have had very similar comments from the health service about local government. That is why it is really important that the current jointly run review between COSLA and the Scottish Government on how well we have progressed so far with integration includes strands around governance and finance in order precisely to address those issues so that we know exactly what is going on and not just what one group of people says versus what another group of people says.

We suggest that another way of doing that would be to look at the Scottish Government directly funding the IJBs. However, another main point in our motion is that there needs to be discussion between the key partners around a financial model that will provide long-term stability for both health and social care in Scotland. The cabinet secretary makes that point herself when she says that they are blaming each other. Why not direct the funding from the Scottish Government directly into the IJBs so that we have transparency?

Moving resources from health to social care is proving to be challenging and progress is not fast enough. Realistically, shifting the balance of care will require investment in social care services if real improvements are to be made. The Scottish Council for Voluntary Organisations raised an important issue around the commissioning of social care services and pointed out that sustainability issues are coming to the fore as the result of factors such as low hourly rates and lack of resources. We must realise that driving down the cost of social care is, in the main, achieved by driving down the pay and conditions of care workers.

My personal experience of home care was when my dad was ill before he died. He had a full care package of four visits per day and, as we spoke to the carers, we discovered that two of those visits were from carers employed by the council and two were from carers employed by an agency. All the carers were brilliant and we could never repay the amazing care and support that they provided to my dad. At the end of the day, therefore, the only difference between those carers was that some were paid a lot less than others, had poorer terms and conditions than others and did not have the same job security as others. Surely, that cannot be right. Surely, we should be promoting a more sustainable model of care that gets the maximum social value from public funds.

That should include more in-house provision so that public funding of care is not used to drive the profits of large-scale commercial providers. Where contracting currently remains necessary, more effort should be made to break up contracts into smaller units, which gives locally based providers a meaningful chance to bid for that work, rather than it going to large commercial chains that are increasingly financially unstable.

Will the member take an intervention?

I am sorry, but I do not have time.

In a survey of care workers conducted by Unison, almost half of carers said that they were limited to specific times with clients. One in two workers said that they were not reimbursed for travel between client visits and three in four said that they expected the situation to get much worse during the coming year. The survey also revealed that one in 10 carers were on zero-hours contracts.

I do not know how many members read the briefing from Enable Scotland, but it made the important point about the treatment of social care workers that

“The Joseph Rowntree Foundation reported in 2016 that 15% of the social care workforce are in in-work poverty. This means that we have Scotland’s most vulnerable people being cared for by Scotland’s most vulnerable workforce.”

The introduction of the living wage was meant to improve the situation. However, I ask the Government to look into the claims that some organisations still do not pay the living wage and therefore that carers are still being paid poverty wages.

I will go further and point out that most politicians in the Parliament queued up to offer their support to the people, mostly women, in Glasgow who—quite rightly—went on strike for equal pay a few weeks ago. However, that begs the question: should we not support equal pay for all workers in the care sector? Poor pay and poor terms and conditions lead to higher turnover and increased challenges in recruitment and training, and they create a false economy.

We know that caring for people in their own home or, if they need it, in a care home is far less costly than caring for people in hospital. Why would we therefore not spend the money that is needed to build a high-quality social care sector that pays well, employs local people and puts care at the forefront of its activities? That would require a significant change in thinking from where we are now and Scottish Labour is calling for that change. We will work with the Government if it is willing to make that radical transformation in social care.

I finish by saying to the cabinet secretary that, right across Scotland, local authorities are reporting that there are massive overspends in the IJBs. We have a problem and we want to work with the Government on it, but we have to face the reality of the situation out there right now.

I move,

That the Parliament believes in a health and social care system based on human rights, where people receive care according to their need, not on their ability to pay; recognises the immediate and long-term challenges to social care delivery and is concerned about high levels of turnover in the social care sector; further recognises the commitment of social care staff to delivering high-quality care but considers there to still be a disparity between the value of social care to society and staff’s level of pay and working conditions; considers that social care workers, and the professional services that they provide, should be held in the same high regard as clinical health care; affirms the Scottish Government’s aim of shifting the balance of care from acute settings into the community but believes that this cannot be achieved without a significant increase in resources and investment in social care services; notes a central theme of the Fraser of Allander Institute publication, Scotland’s Budget Report 2018, that it is not sustainable to protect the health budget at the expense of local authorities’ budgets, and calls on the Scottish Government to work in partnership with local government and NHS boards to develop a financial model that will provide long-term stability for both health and social care in Scotland.

I call Jeane Freeman, the Cabinet Secretary for Health and Sport, to speak to and move amendment S5M-14717.3. You have six minutes, cabinet secretary.

14:49  

In this role, I have the privilege of meeting people who benefit from social care and people who provide it. Although those who I have met and heard from have been resoundingly positive about many aspects of the service that they receive, or the work that they do, that experience is not universal.

I welcome the opportunity to have this debate and to hear what members say and I am grateful to Mr Rowley for lodging the motion. I know that we need to continue making improvements. I also know that that task does not sit with Government alone. We must use the partnerships that we have and nurture with local authorities, the NHS and integration joint boards to harness our collective experience and efforts and to make improvements where they are needed.

In the health and social care financial framework that I brought before the chamber in October, we recognised that services needed to change, particularly as we enjoy longer lives with more complex needs. A key component of that change is the delivery of integration in health and social care. Integration is the most significant reform to health and social care services since the NHS was created in 1948. However, integration is not an end in and of itself. It is a tool—a means—through which we collectively deliver better services for people. People do not and should not have to care about whose budget the service or the support that they need comes from. They want our collective focus and work to be driven by their needs as a whole person. They want the support that they need to be safe and effective, and they want the right support in the right place at the right time.

Integration brings together almost £9 billion that was previously managed separately in health boards and councils. This year’s funding includes more than £550 million of NHS front-line investment to support integration and social care.

That whole-systems approach needs to be focused on safe, effective and, crucially, person-centred services. It also needs whole-systems thinking. In that regard, I am at one with Mr Rowley in emphasising the importance of our looking at and thinking about the system as a whole. That is radically different, and it is challenging.

To deliver the significant shift that we need in thinking and delivery as fully as it is needed will, of course, take time. However, we will do that together. With COSLA, we are reviewing how far we have come, identifying where we are getting it right, working out what we need to do to scale up the good practice that exists and, crucially, considering what more we need to do to learn and apply the lessons and to continue to build the momentum of improvement.

With COSLA, we are committed to the delivery and upcoming expansion of free personal care. Scotland continues to be the only country in the United Kingdom that provides free personal care. We provide 76,000 over-65s with free personal care. From April next year, that will be extended to those under 65.

The social care workforce provides care to people the length and breadth of our country. We want to help those workers to develop, so we have provided funding for all adult social care workers to be paid the real living wage. That has benefited up to 40,000 care workers. Like Mr Rowley, I have heard and have correspondence from individuals in organisations who are adult social care workers, who have yet to benefit from the funding that the Government provided.

That is a shared problem between COSLA and the Scottish Government. With COSLA, we need to look at why those funds are not being passed on to deliver that commitment, which, I am sure, is shared across the chamber. Fixing that does not lie at the hands of Government alone. I am sure that members would be quick to criticise the Government if we got into the business of instructing local authorities what to do.

Has the cabinet secretary read the Enable Scotland briefing? It says:

“Third sector providers like Enable Scotland are forced to either fund uplifts in staff pay from reserves or other revenue streams, or tell our staff that we’re simply unable to pay the Scottish living wage for every hour worked”.

What is her response to that?

I am grateful for that question. I have read the briefing—I have read all the briefings that came in for today’s debate, as I properly should. My response to Enable Scotland—which, along with Sense Scotland, I expect to meet shortly—is that that is in the nature of the contract that it has with the local authority, so it needs to take up the matter with the local authority. [Interruption.] We provide the funds. The contracts are between the local authorities and the providers.

If Labour members want the Scottish Government to be responsible for those contracts, I wonder whether they have had conversations with COSLA about those powers being taken away from local authorities. If that is what they want, I will have that discussion. I will work with Enable, Sense Scotland and any other organisation that has not received those resources through the contract—part of which we have funded to ensure that the real living wage is paid—and I will take up the issue on their behalf, alongside them, with the local authority. I urge Elaine Smith and all members to do precisely that as well.

We will publish an integrated health and social care workforce plan for Scotland in the near future. As part of the development of that plan, we have published specific recommendations that cover the social care workforce. Those recommendations directly address recruitment challenges, promote career pathways and improve workforce development in social care. That plan, like others, has been developed alongside our colleagues in local authorities, the third sector and, in some instances, private sector providers too.

As we look at our workforce—

I am afraid that you must conclude there, cabinet secretary. I am terribly sorry, but this is a short debate.

I took an intervention.

Yes, but even with that you have had nearly another minute. Please move your amendment.

I move amendment S5M-14717.3, to leave out from “services; notes a central theme” to “Scottish Government to work” and insert:

“, primary care and mental health services over the current parliamentary session; further believes that protection of the health budget, and its investments in social care, is necessary to ensure that the NHS can be sustained long into the future; notes that, with investment from both the NHS and local authorities, almost £9 billion per year is managed by integration authorities; believes that the additional investment of £66 million in this financial year to support social care, including for delivering the real living wage for adult social care workers, supporting the implementation of the Carers (Scotland) Act 2016 and increasing payments for free personal care, should be utilised for that purpose, and recognises the publication of the medium-term financial framework for health and social care, which was advanced by the Scottish Government”.

Thank you. These short debates are always awkward for the chair. I call Miles Briggs to speak to and move amendment S5M-14717.1.

14:56  

I am pleased to take part in today’s debate and I thank the Labour Party for bringing this important matter to the chamber. Social care is one of the most important issues that our country faces and it is of great concern to many older and vulnerable people and their families and friends across the country. I thank and pay tribute to the organisations that have provided useful briefings for today, including the SCVO, Enable and Age Scotland.

The Scottish National Party Government and the First Minister have said repeatedly that they will get on top of the delayed discharge crisis in Scotland, which is one of the clearest indications of the pressure on social care networks. Indeed, the former Cabinet Secretary for Health and Sport, Shona Robison, promised three years ago that the Government would “eradicate” the problem, but the reality, as shown by the most recent Information Services Division figures, is that the situation is deteriorating, and the Government shows no signs of knowing how to turn the problem round.

The most recent figures show that in September, 1,529 people were forced to stay in hospital despite being fit to leave, mostly because of an inability to arrange appropriate at-home care packages, but also because of a lack of suitable care home places. That figure has got worse over the past two years. Perhaps most concerning was the recent case highlighted in The Sunday Times of delayed discharges of between four and seven years at some health boards, with a patient deemed fit for discharge by a Scottish health board in 2011 still under NHS care, according to the Mental Welfare Commission for Scotland.

I recently met representatives of MND Scotland, who highlighted to me a number of cases across Scotland in which, due to failures in community social care, people ended up admitted to hospital, where their condition significantly deteriorated. As my amendment points out, today’s debate highlights the real need for joint working with housing associations, to ensure that delays in making necessary home adaptations do not further contribute to delays in getting people out of hospital.

The delayed discharge crisis is particularly acute in my own Lothian region, with delayed discharge rates higher here than in any other part of Scotland and accounting for almost a quarter of all of Scotland’s delayed discharges. The City of Edinburgh Council has more delayed discharges than any other council in Scotland. I commend newspapers such as the Edinburgh Evening News, whose on-going care in crisis campaign is helping to keep up the pressure on the city’s health and social care partnership.

Not a week goes by when I do not receive correspondence from constituents and families who come to ask for help when they find themselves in situations that cannot be resolved because of the clear breakdown in our social care system here in the capital. The inability of local health and social care partnerships to provide sustainable care packages is in large part due to the recruitment crisis in the social care sector. Edinburgh’s health and social care partnership has said that local contracted providers have reported high staff turnover rates, which are in the region of 30 to 50 per cent.

Will the member take an intervention?

I warn you, Mr Briggs, that there is no time in hand. You will have to absorb the time taken by any interventions.

I will say this very quickly. Does the member recognise that in Edinburgh there is particular pressure in the labour market and that both the local authority and NHS Lothian have jointly contributed additional funds to meet that?

I have been calling for that for two years and I met the health board to say that it needs to be put in place. We have an overheated market here in Edinburgh, which is contributing to that factor.

I agree with Alex Rowley: it is important that we recognise that we need to encourage and support our social care workers. They are fulfilling a vital role and should be held in the same regard as clinical staff and other NHS workers.

Although investment in extra childcare is, of course, welcome, the Government needs to be aware of the impact that the situation will have on the adult and elderly care workforce and of the additional staff that will be needed.

The Scottish Government will need to address those concerns without delay and look to how we can ensure that social care workforce plans are brought forward more quickly. The Parliament’s Health and Sport Committee undertook an inquiry into the social care workforce and made a number of important recommendations, which we have not seen progressed or implemented to date. Some of those were highlighted by Alex Rowley.

A national social care internship programme, for example, merits consideration and could be a good opportunity to give students who are studying relevant courses practical experience in the field. I hope that that is something that the Scottish Government will agree to explore. Such a scheme could be taken forward by colleges, universities and social care providers. It is important in order to meet what is now a real demand for additional staff in the social care workforce across Scotland.

The Parliament’s Health and Sport Committee in its recent report also looked ahead to this year’s budget and expressed serious concerns about the leadership in some of our health and social care partnerships and about the failure of too many partnerships to deliver the transformational change required.

You must conclude there, I am afraid. I have to be the same with everyone. I am sorry about that—I beg your pardon.

To conclude—

You have had five minutes. Sorry, Mr Briggs, but I have no time in hand. Please move your amendment.

I move amendment S5M-14717.1, to insert at end:

“, and further calls on the Scottish Government to focus on improving workforce planning and consider new models of care and joint working, including working with housing associations to tackle delayed discharge to prevent patients waiting in wards because their homes need to be adapted for their return.”

15:01  

I thank Labour for bringing this debate to the chamber and I welcome the opportunity to discuss the future of social care in Scotland. I am heartened by the progress that is being made to make personal care and nursing care free to all who need it, regardless of age or condition. It was deeply unfair that free care was limited by age, and I believe that the change was won because the Government listened to voices across parties, constituencies and communities. We all understand how integral high-quality social care is to our entire health and social care system, and that should be reflected in housing and our fair work practices, too.

I hope that this debate allows us to make further progress in agreeing shared priorities for social care. No discussion of care should fail to recognise the incredible contribution that unpaid carers make. Health and social care budgets are stretched, and we can only imagine how much worse that would be without that incredible contribution, which we should better recognise through a more generous and more widely available Scottish carers allowance.

I turn to pay. I whole-heartedly agree with the point that was made in Labour’s motion that there is still a disparity between the value of social care to society and the level of pay and working conditions of staff. Investment that the Scottish Government has made in the living wage for social care workers has been welcome, although clearly there are problems and not all workers are receiving that yet.

We cannot and must not stop there. The Scottish Greens have long called for a living wage plus for social care staff. A rate of at least £10 per hour for social care staff would reflect how important their work is to our communities and public services and show our high regard for the specialised caring role. Such investment would significantly boost women’s pay, given that women account for about 85 per cent of the social services workforce.

I would also like the Scottish Government to commit resources to the delivery of meaningful pay differentials among staff who are building careers in the sector. Such direct support would encourage staff to develop into specialised, senior and management roles, with increased responsibility.

Such an approach would also help to address the serious staff shortages and high turnover in the sector. Scottish Care indicates that average turnover in care homes is 22 per cent. As Age Scotland points out, that is likely to be compounded by Brexit, given that at least 6 per cent of our social care staff are European Economic Area nationals, as are around 8 per cent of nurses in the sector.

Given that more European Union nurses are leaving the Nursing and Midwifery Council’s United Kingdom register than are joining it, enough damage has been done already. The British Medical Association and the Royal College of Nursing are campaigning for a people’s vote, and in the light of Labour’s motion on social care, I urge members on that party’s benches to join in that campaign.

To ensure that social care services are sustainable, an increase in resources is necessary, as well as efforts to safeguard existing staffing levels in the face of Brexit and to improve workforce planning, but there does not yet seem to be a strong consensus on how increased resources should be directed to front-line social care services. The motion calls on the Government to develop a financial model to address the issue in partnership with local government and NHS boards, and it is fair to recognise that the Government has work under way in that regard—Audit Scotland has welcomed the medium-term financial framework for health and social care.

The Greens will support the Labour motion, but I point out that, in “Scotland’s Budget Report 2018”, the Fraser of Allander institute stresses that

“Spending choices should not just be viewed as a trade-off between local government and health”.

When the aim of integration is for spending on health and spending on social care to be mutually supportive, we must move away from considering one budget to be protected at the expense of the other. Both need to be properly funded.

15:06  

Every year, 500,000 bed days are lost to the NHS because of delayed discharge. The issue is one that was supposed to have been resolved almost three years ago—the cabinet secretary’s predecessor gave that commitment. I am not pretending that the problem is an easy one to solve, but there is a significant difference between the rhetoric of three years ago and the reality of today.

My concern about the integration authorities is that we have not created integration; we have created a separate, third body that is junior to the council and the NHS board in the area. When difficulty arises, those two bodies are nowhere to be seen. That is one of the challenges that we face. We have not created the integration body that we need.

The high turnover of leadership in the integration authorities is of grave concern. Seven out of the 31 authorities have had new chief officers in the past two years. There is a lack of long-term financial planning as well as a lack of data sharing. We know about the problem of the different languages that the professionals in the different halves of the organisations speak. There is a lack of collaboration between the bodies, and accountability is confused. All of that has led to 500,000 bed days being lost to the NHS every year.

The bed days figure gives an indication of the health of a hospital, because it shows the flow through the hospital. Although accident and emergency waiting times are important, the bed days figure is probably a stronger indicator of how well a hospital is performing. That is why it is so important that we get on top of the problems that we are discussing.

I will quickly give some examples of where the system is not working in Fife. There is a proposal to close the general practitioner out-of-hours facility in St Andrews, which is a responsibility of the integration authority. NHS Fife has distanced itself from the decision. Fife Council tells me that the individual councillors on the health and social care partnership are there in their own right, not on behalf of the council. If the partnership is a joint body, both the health board and the council should be responsible for its decisions, but both are distancing themselves from the proposal to close the St Andrews facility, even though the co-leader of Fife Council—I will not say which party he represents—voted for it. The whole thing is a shambles, which is why people in Fife are very confused about who is responsible for anything.

There is also turbulent leadership in Fife. Michael Kellet, the chief officer of Fife health and social care partnership, is a very good officer, but he is relatively new in the organisation. We have just lost the previous chair of the body, Simon Little—he was prematurely removed from the board. That has removed the continuity that we need. One of the wider concerns that I have raised about the performance of NHS Fife and its leadership is the fact that we have had four departures from senior positions in the body in the past two years, and I hope that the Scottish Government commissions an investigation into that.

The integration authorities have other fundamental weaknesses. There is a shortage of workers, particularly in rural areas, where workers are not paid to travel between homes to care for individuals. It is no wonder that we are finding it difficult to get carers to cover rural homes and rural patients.

Brexit, of course, is compounding the problem, which is why we need the people’s vote that Alison Johnstone talked about. Robert Kilgour has talked about the impact of Brexit in this “perfect storm”—the combination of different issues impacting on the care service.

Finally, the removal by Bield Housing & Care of 12 of its care homes is surely another indicator that the sector has serious problems.

We move to the open debate. We are already behind time, so speeches of under four minutes would be useful.

15:10  

On many occasions in Parliament, members have commended the skills and professionalism of people who work in the social care sector, and rightly so, because for many families throughout Scotland, a good quality of life and engagement with the wider community are entirely dependent on the support of social care services.

Investing in the social care sector contributes to the preventative spend agenda by keeping people healthier and active in their own homes and, as we have heard from other members, by releasing hospital beds for those who need them most. Social care sector workers, who are mostly women, make a significant contribution to the local economy by earning and spending in our communities.

I am sure that there will be agreement across the chamber that such essential work should be valued accordingly. As such, the targets that have been set on the payment of the living wage across the sector are to be welcomed, and I am sure that the progress that has been made has improved the earnings of many households. However, too many of the children who live in poverty in Scotland live in households in which at least one adult—often two—is in work, so we should be asking whether simply delivering on the living wage alone is adequate in meeting the needs of families or, in this instance, in recognising the value of the social care sector.

Implementation costs for the payment of the living wage as a minimum across the sector appear to be unclear. Last week, the Coalition of Care and Support Providers in Scotland commented on two recent research reports. Its survey of the experience of its membership showed that providers have, in the main, kept up with living wage increases, but the reality is that less than a third of the organisations

“secured sufficient funding from Living Wage-earmarked resources to cover the cost.”

That must mean that other aspects of the service suffer.

Staff recruitment and retention are known to be problems already. If overall staffing capacity has to be reduced, there will be more pressure on existing staff to do the work, sickness and absence levels will increase and job satisfaction levels will decrease. That is no way to run a service on which so many of our citizens depend.

Recent research by the University of Strathclyde looked at the experiences of those who are involved in delivering the payment of the living wage across the sector. Although it recognised some of the progress that has been made, the research report highlights almost 32 different approaches to implementation across our local authorities, time and resources being wasted and undue strain being placed on some organisations and departments.

Looking to the future, we know that the social care sector, including the voluntary sector providers that work in partnership with local authorities, needs financial support to bring in new staff. That means younger staff, a more diverse workforce, staff who might be starting or bringing up a family and staff who need well-funded maternity and paternity leave, sick pay, pension rights and good terms of employment, in order to meet the aspirations of the fair work framework that has been set out by the Government.

Annie Gunner Logan, CCPS director, said:

“The findings outlined in these reports suggest that the delivery of the Living Wage in social care has been made a practical reality at least in part by a significant transfer of financial responsibility and risk to the voluntary sector, with concomitant pressure on the sector to bail out the policy with a pretty whopping level of subsidy.

The First Minister has made a commitment to extend Fair Work, including the Living Wage, to as many funding streams as possible through public procurement. We warmly welcome that commitment and want to see it happen as soon as possible. But this new research shows clearly that the implementation process needs a complete overhaul if this policy is to have a positive lasting legacy.”

Both reports raise serious questions about a longer-term commitment to improving pay and conditions across the sector. Our social care workers deserve far better. The Scottish Government must indicate how it intends to address the specific concerns and take seriously the need for more investment in this key employment sector in Scotland.

15:14  

Today’s motion on investing in social care for Scotland’s future states that the

“health and social care system”

is

“based on human rights, where people receive care according to their need, not on their ability to pay”.

I absolutely agree with that statement. A key priority for the Scottish Government is to ensure that the needs of people who experience care come first and that their rights and choices are respected.

Like many members in the chamber, I recognise the immediate and long-term challenges to the delivery of care in people’s homes and, indeed, in the community. I also recognise that there are challenges to demonstrating and elevating the value of people who choose to look after those who need care.

In preparation for the debate, I was reminded of my nurse training—I remind members that I am a registered nurse. When I started my training, I learned about Abraham Maslow and his theory of the hierarchy of psychological health needs. His paper, which was published way back in 1943, is still relevant today. His hierarchy of needs describes the basic needs for survival—food and water, shelter, warmth and safety. Carers provide support and care that meet the basic needs of human beings and, while engaging in their caring duties, support clients and service users in many other ways. Maslow’s hierarchy of needs is as relevant today as it was in 1943.

I agree that attracting the right people to become carers and retaining them, as well as raising the status of social care as a profession, is key to delivering quality care. The SNP Government has taken action to protect our social care services and to ensure that adult social care workers are paid the living wage. That move has benefited up to 40,000 carers, many of whom are women, as Elaine Smith highlighted.

Will the member take an intervention?

I am sorry, but I am not taking an intervention, because time is tight.

In addition, the SNP Scottish Government has ensured that, this year, there will be more than £550 million of NHS front-line investment in social care and integration. Around £66 million of that will enable local government to better support social care, including through the continued delivery of the living wage for adult care workers, and it will cover the extension of sleepover hours during 2018-19.

Ensuring that the workforce is properly trained, supported and regulated is key to effective, safe and high-quality delivery of services. That is exactly what the Scottish Government is doing and will continue to do. Moving and handling is one of the key skills required by both paid and unpaid carers to prevent injury. I have had representations from a constituent in Ayr who has asked me to pick up on that, and I have written to the cabinet secretary on the matter.

I support the Government’s amendment, which speaks of increased resources and investment in primary care. In my South Scotland region, a programme called transforming Wigtownshire is working with local people across rural south-west Scotland. I have spoken about it previously. Its goal is to generate ideas and different ways of working so that social care resources can be delivered in the most effective way. The programme is under way, and European Union funding has been applied for and is available for investigations of how the implementation of technology can be used to support people in their homes, so that they remain independent and supported and can get out of hospital sooner. That technology, including mPower, the community health synchronisation project—CoH-Sync—and, now, the attend anywhere programme, is being piloted and tested in the area. I look forward to seeing the outcomes as they become available.

In conclusion, I support the Scottish Government’s amendment and agree that social care must be a fundamental right and that people working in the sector must be recognised and paid a fair wage.

15:18  

The concept of integrating health and social care has unanimous support across the spectrum in politics and the professions. It is the ultimate no-brainer. The policy would deliver a better care system for the over-65s, enabling people to stay in their own homes and communities; would reduce the use of acute health services, improving everyone’s quality of life; would ultimately help to address the challenges of our increasing longevity; and, while improving lives, would deliver a more financially sustainable outlook.

That view has not changed, and the support for Frank’s law reinforced the belief that the provision of free personal care for people who need it is an important social principle. However, despite that unanimous support, the delivery of the principle is still facing a number of hurdles, not least the conflicting interests of local government and the health service. In the early days, it was a battle of language and understanding between two different cultures; today, it is more a battle of resources and control.

In 2011, the Christie commission into the future delivery of public services identified five key issues: that services were provided to individuals rather than designed for and with them; that models of provision failed to empower and enable people and communities sufficiently to achieve positive outcomes in their own lives; that services often impaired individual incentives and fostered dependencies that created demand, while a culture of professional dominance in public bodies had made them unresponsive to changing needs and risk averse about innovation; and, finally, that procurement was often taken forward on a scale that discriminated against smaller providers and person-centred approaches. The question is: how far have we gone in addressing those challenges?

There is a real tension between the key partners. The health service needs patients to be able to leave acute care in a timely manner, because delaying discharge is not only an expensive option but a poor option for the patient—particularly for the elderly—as people can become institutionalised and lose their independence through reduced movement and risk of infection. On the other hand, local government is feeling the strain on its budgets and is seeking solutions to the increased pressure to provide more services to a burgeoning elderly population.

I do not believe that the competing interests of those two bodies, no matter how united their press releases are, provides the best approach to meeting people’s needs. There is a clear lack of leadership as integration joint board members have half an eye on the interests of the bodies that appointed them to the IJBs. I say that not to be disparaging of IJB members but in recognition of the fact that it is a difficult balance to get right. The reality on the ground is that people just want good services—they do not care who is in charge, but somebody needs to be.

Delivery of a high-quality social care system requires motivated and caring staff. Pay certainly has a role in that, but so do conditions of work and, most important, job satisfaction. Many elderly people develop positive caring relationships with those who come in to assist them, but there are difficulties. When I speak to care staff, one of the concerns that they consistently raise is the lack of time that they have in which to deliver the care that they would like to deliver. The period of 15 minutes that is often allocated is not long enough to support some people effectively. Both the client and the carer struggle with that, and it fails the person-centred care test.

We need transformational change. I am not suggesting that no good work is being done on the ground, and I certainly welcome the independent inquiry that is under way. However, as yet, integration of health and social care is still very much a work in progress.

15:22  

In the short time available to me, I will cover two specific issues, both of which relate to the importance of the social care workforce. We know that the quality of social care is fundamentally about resources, and the biggest resource of all is the workforce. Without that dedicated workforce, the system would simply collapse. We know about the challenges of recruitment and retention in social care, and there is no doubt in my mind that they will be exacerbated by Brexit, but there is much that we can do.

The sector is growing and the need for social care is increasing. Whether it is someone with a learning disability who needs support or an older person requiring a night-time tuck-in service, the care that is provided is essential to their wellbeing. Recently, the Economy, Jobs and Fair Work Committee recognised, for the first time in the Scottish Parliament’s history, that care is a key growth sector that matters fundamentally to our economy. The committee recommended that Scottish Enterprise treat it as such but, unfortunately, ministers thought otherwise. I ask them to think again, because caring and the jobs in the sector make a hugely important contribution to the Scottish economy.

The workforce is predominantly feminised and is characterised by low wages and part-time temporary work. That needs to change. We, as a society, need to value the service that carers provide, and one obvious way of doing that is through their pay packets. The Scottish Government allocated additional money for local government to pay the living wage for waking-hours care from October 2016. Scottish Labour campaigned for that, and I welcome it very much. During the passage of the Procurement Reform (Scotland) Bill, the SNP refused our calls for the Government to pay the living wage to all employees on public contracts, but I am glad that it has changed its mind and has done that for social care staff.

I welcomed, too, Shona Robison’s announcement in October 2017 that the living wage was also to apply to staff providing night-time cover. That was to be implemented this year, in 2018-19, and the Scottish Government gave additional funds to health and social care partnerships to do it. The living wage was to be in place for all staff, whether for daytime or night-time cover, and not just for those employed directly by the local authority but for those employed in the private and voluntary sectors.

However, the reality on the ground is very different, as we have heard from members today. I will tell members about the experience of one of the largest third sector providers of social care. It is keen to pay its staff the living wage for sleepovers, and their trade union is keen for that to happen. However, the delivery of the policy on the ground is patchy. Services that are commissioned by local authorities for the full year have been commissioned already without payment of the living wage for sleepovers; in fact, some 60 per cent of local authorities that commission care services have not provided the living wage for sleepovers for the entirety of 2018-19.

I cannot believe that the cabinet secretary is content with that. Money that has been given to pay the living wage is not ending up in the pockets of hard-working care staff, where I know she wants it to be. We all want it to be there, and I cannot believe that the cabinet secretary is happy that it is not. Will she ensure—we will help her—that, for the remainder of this year, that money is paid so that the staff get their rightful pay? Will she guarantee now that the policy will be fully funded for 2019-20 and that all staff who do sleepovers will be paid the living wage?

It is 41 days away from Christmas, and the panto season is already upon us. Will Jeane Freeman be Santa or Scrooge? Social care workers are watching with interest. I hope that she is Santa.

15:26  

Money is being invested in health and social care integration. Health spending per head is 7.1 per cent higher in Scotland than in the UK as a whole, which represents £850 million more in spending on health services in Scotland. Given that Labour has brought the debate to the chamber, it is worth remembering that Labour’s spending plans for health at the last Scottish election would have seen our NHS cut by being £360 million worse off—that is the equivalent of 9,000 nurses.

Rather than deliver the full funding, the UK Government has cut our budget by almost £55 million next year and by more than £270 million over its five-year plan. However, despite the UK Government’s cuts to Scotland’s budget, an additional £66 million will be provided to local government to support the Carers (Scotland) Act 2016, which I hope will be welcomed by everyone.

The Scottish Government’s priority is to ensure that the needs of people who experience care come first and that their rights and choices are respected. Within the past decade, a significant amount of work and investment has gone into supporting older people and people with disabilities to live well in their homes for longer. As a population, we are living longer, which means that demand for care and support is growing faster than our traditional services were designed for. The challenge of looking after our ageing population in the future is one that we all must face head on. As other members have mentioned, Scotland is the only part of the UK to have implemented free personal care for older people and will be the only part to implement it for people under 65. All in all, we have a system that, although it is not perfect, is much fairer.

In general, there has been cross-party political consensus on the issue of integration. Given the importance of the issue, that is right. This is the second time in a week that I have spoken on the issue after contributing to Monica Lennon’s members’ business debate last week—a debate that was used to criticise decisions by an SNP council to reduce the need for care homes and support independent living. I pointed out at the time that those decisions were initiated under the Labour administration—and rightly, too. In that debate, Monica Lennon and her colleagues failed to address the fact that neighbouring North Lanarkshire Council, which is under Labour control, is now down to just one care home. I am not going to be a hypocrite, however, as I agree with that situation—it is a sign that we are supporting more people to live at home.

Will Fulton MacGregor give way?

I am sorry, but I do not have time for interventions.

In that debate and today’s, the workers’ situation, which Alex Rowley and other members have mentioned, is a theme in which I have found some common ground with Monica Lennon. We must work with the social care workforce to find the right employment for everyone.

Will Fulton MacGregor take an intervention on that point?

I cannot.

That is why the SNP Government has provided funding to enable adult social care workers to be paid the Scottish living wage—last week was Scottish living wage week—which has benefited up to 40,000 care workers, as Emma Harper pointed out. The average earnings of adult social care workers are higher in Scotland than elsewhere in the UK. That point has been talked about a lot.

I welcome the cabinet secretary’s remarks that she is willing to address some of the concerns that have been raised about people not being paid the living wage when they are employed through third sector organisations. Of course, our system is not perfect; no one is denying that. It cares for some of our most vulnerable people and needs to be flexible and responsive.

I am sure that all members here have had queries from people who are unhappy about the level of care that they or their relatives have received or who are unhappy about local decisions such as the reduction in community alarms and gardening services, which has knock-on effects on personal care. Politicians at all levels of government must respond honestly to those issues and learn from them to make the system as effective as we can.

Like Alison Johnstone, I must mention unpaid carers, as the work that they do is absolutely fantastic.

We must work collaboratively on this—it is one of the biggest challenges of our generation.

Brevity from the final two members to speak in the open debate would be appreciated.

15:30  

The decision to integrate health and social care and to seek to shift the balance of care out of hospitals and into our communities was fundamentally right.

However, it has been something of a challenge to find a way to put those ambitions into practice. Having seen at first hand the integration joint boards when they were first set up, I was, as a councillor, acutely aware that councillors, NHS board members and officers from both organisations took some time to adapt to the new way of working. People must continue to adapt to it if they are to make progress on social care. At present, the increasing costs that are caused by the pressures of an ageing population are outpacing the rate of transformational changes being made by integration authorities.

A recent report by the Health and Sport Committee suggested that that was due to a lack of leadership in the integration joint boards. If they have a leadership issue, that is a real problem that must be tackled. The report also highlighted concerns that some senior managers are directly linked to one of the partners and therefore might have conflicts of interests when budget decisions are being made.

More concerning, however, is the lack of formal joint working arrangements between NHS boards and local authorities, which would allow one manager to have responsibility for staff in both organisations. Although teams of staff from both partners often work together, true integration will continue to elude us if we do not tackle the problem.

There are still concerns about the governance ability and arrangements of some integration joint boards. Although the integration schemes may allow for shared overspends between partner organisations, they are not a requirement, so local authorities may have to pick up the bill for significant increases in demand pressures. It is very important that we look at how budgets are managed, because we must ensure that we do not go from having had two authorities that failed, to just replacing them with three authorities that might also be failing.

We need to ensure that we do more to improve delayed discharge, including through improved sharing of information. In Perth and Kinross, the home assessment recovery team seeks to get people out of hospital and back into their own homes as soon as is practically possible by putting in place the necessary adaptations. It also provides temporary care to help people to readjust to being back in their home before they get the permanent package of care that they require. That model has been successful in reducing the number of delayed discharges, and could be replicated in other areas.

However, all those considerations are rather academic if we are unable to recruit staff to provide the required services. The Care Inspectorate recently said that 35 per cent of care services in 2015-16 had unfilled staff vacancies, and Scottish Care said that the proportion of homes requiring full-time nursing posts to be filled has increased. We need to look at ways to make those jobs more attractive to people who are otherwise put off working in the sector.

We have made progress along the road to health and social care integration, but there is still much work to be done. We should continue to monitor the Public Bodies (Joint Working) (Scotland) Act 2014 to ensure that it is being implemented, and we should consider how the Scottish Parliament can support the development of integration authorities. If that is achieved, it will go a long way towards tackling the many issues in the sector.

15:34  

I emphasise that we have made significant progress in recent years. In particular, I welcome the introduction of Frank’s law and the living wage, and the increase in the carers allowance, all of which are making substantial contributions to the improvement of social care.

We all know that there are major challenges still to be faced, but it is worth our while to remind ourselves why integration is so important. The policy of integration is driven by the medical and economic evidence. The medical evidence is that patients are treated better and more safely at home—if they can be treated at home—than in a hospital setting. I remember the following statistic because I got it on my first day as the then Cabinet Secretary for Health and Wellbeing. At any one time in Scotland, or indeed in any advanced economy, about one third of the patients who are in hospital do not need to be there: it is not to their medical advantage to be there. That is why we must—as has been done successfully elsewhere, most successfully in Alaska—transfer those people and their treatment into the community instead of leaving them in hospital.

There is an unusual situation in that as well as treatment at home being medically the best way to treat patients, it is also the least expensive way. In the health service, the best treatment is usually the most expensive treatment; social care is, ironically, the least expensive. On average, it costs almost £4,500 a week to keep a person in an acute hospital, about £2,000 a week to keep them in a community hospital, £700 a week to keep them in a nursing home, and £300 to £400 a week to keep them at home. There are, therefore, both medical and resource issues that should drive integration as fast and as comprehensively as possible.

The core issue is the same issue that we faced when it came to emptying the Victorian asylums and treating in the community people who had mental health problems. We must fund both services to the same level until the transition has been made. We must continue to fund acute services, which is what the set-aside money is for, while building up the resources that do not currently exist in the community. If we are going to empty the hospitals of people who do not need to be there, we need to have the appropriate facilities in the community. We are trying to achieve that against a background of severe budget constraint that is not of our making.

Bridge funding was supplied for the Victorian asylums, which was a kind of equivalent to the set-aside money. We can learn lessons from what was done with mental health treatment as we try to achieve our objective with physical health. However, there should be no misunderstanding: it is a complex issue, and although we have made substantial progress, there is still a lot to be made.

I will leave it there, Presiding Officer. It is a great pity that the debates are being squeezed by the Parliamentary Bureau. It does no service to the Parliament, no service to the subject of social care, and no service to the next debate.

We move to closing speeches. Brian Whittle has no more than four minutes.

15:38  

I am delighted to be taking part in the debate, and I thank Labour for bringing the issue to the chamber. It has been an interesting debate on a subject that could, as Alex Neil has just said, have done with more time for members to develop the main points. The fact that there has been little attempt to leverage political discourse into the debate highlights how important the subject is.

Alex Rowley started the debate by highlighting how problems between the NHS and social care services are leading to delayed discharges. Miles Briggs developed the point and suggested that the level of delayed discharges indicates the pressure that our social services are under.

I highlight that we agree with much that is in the Scottish Government’s outline vision and objectives. It is entirely right that we should aim for everyone to live longer and healthier lives at home or in a homely setting. Alex Neil focused on the fact that treatment at home is medically and financially the better option. That should receive support from across the chamber.

Central to that vision is the development of integration joint boards. In his speech, Alexander Stewart highlighted the fact that initiating such a fundamental change will inevitably hit bumps in the road.

However, as the Health and Sport Committee reported, plans for measurement of health and social care are being hampered by lack of leadership, which Michelle Ballantyne raised in her speech. There is a sense that there is no governing body steering the ship. Willie Rennie was keen to develop that issue. At this point, 21 integration joint boards are failing, after three years, to deliver the transformation that is required.

That view is backed up by an Audit Scotland report that states that progress towards the 2020 vision is “too slow”. That report also mentioned that financial sustainability of the health service in the medium to long term and recruitment of the right number of key staff are key.

Workforce planning, or the lack thereof, was one of the main thrusts of today’s speeches and the Labour motion, and we have heard calls for a cohesive strategy to alleviate the shortage of trained healthcare professionals. We are certainly able to support some of the SNP policy at the top level. However, when we look below the surface, we can see that more thought is required in order to create a sustainable and stable workforce.

I would like to highlight the unintended consequences of lack of forethought and planning in relation to the policy of providing 1,140 hours of free childcare for three and four-year-olds. It is a fact that, now, carers are transferring from the social care environment to the childcare environment, because the same skill sets are needed in both areas. Only a couple of weeks ago, nursery owners told me that they are recruiting more and more staff from the social care sector. The matter has been raised time and again in the chamber, but the Government has been slow to react and to recognise that all social care and health policies are interconnected and interdependent.

Integration of social care and healthcare is the way to go, and we support the drive to achieve it. However, there is an issue with governance in relation to implementation of the policy, as was highlighted in the inquiry by the Health and Sport Committee. The best that one can say is that progress on delivery is patchy across the country.

I call Jeane Freeman. You have no more than four minutes, cabinet secretary.

15:42  

I will do my best to rattle through my speech.

We are, undoubtedly, faced with challenges as we seek to deliver integrated health and social care properly. However, Alex Neil was absolutely right to say that we should not set aside recognition of the significant achievements that have been made in many local authority areas by social care workers. We must give them credit for what they have done.

It is right for members to have pointed to delayed discharge: there are undoubtedly challenges there. However, as Alexander Stewart said, we have integration authorities in which there is no delayed discharge and things are working. The one in his local council area is not the only one in which that is the case. The issue is not only about resources; it is also about how we work, which is why I spoke earlier about the whole-system thinking that is needed.

Willie Rennie pointed to issues in governance and leadership, and was not alone in that. Without specific reference to the situation in Fife, which would not be appropriate, it is right that the joint review that I mentioned, which is led by COSLA and the Scottish Government, is actively looking at issues of governance, finance and decision making.

The approach is three years old—a lot has been achieved in those three years, but the approach is still new. I completely appreciate that someone who is waiting for better services does not care how new or old the approach is, and simply wants the improvements now. However, I think that that perspective is a reasonable one for us to have. Furthermore, it is right that the review is a partnership.

Alex Rowley made an interesting proposition about directly funding integration joint boards. I presume that that funding would come from the health service and local authorities. I am happy to discuss that with COSLA and to consider changes to ensure that our Government procurement framework is applied or is, at least, matched in local authorities, and I would certainly welcome the support of Mr Rowley and his colleagues in doing that, because I do not think that local authorities would take kindly to the idea of responsibility for people whom they currently employ being lifted from them and moved elsewhere.

Jackie Baillie offered to help to ensure that the money that the Government has provided to fund fully the real living wage gets to the staff who deserve it. I welcome that. Therefore, I invite her to be Santa by working with me to ensure that all councils do precisely that, not only for the people whom they employ, but for people whom they contract, including from the third sector. Together, let us learn the lessons from local authorities that directly employ social care staff, and in which terms and conditions, career opportunities and the real living wage are such that the authorities not only attract staff, but retain them.

Will the cabinet secretary take an intervention?

No, I shall not.

In authorities where that is the case, we see that the clear guidance that 15-minute visits are appropriate only in certain circumstances, for example for medicine checks, is followed. Those integration authorities are moving away from the time-and-task approach to focus on the individual.

The workforce is important—I am interested in Miles Briggs’s proposition of a social care internship and am happy to discuss that with him. As others have mentioned, we cannot talk about the importance of the workforce, and the importance of recruiting and retaining it, without recognising that we must do that in the context of Brexit. Brexit will take away a significant proportion of our current social care workforce. We need not only free movement in order to continue to benefit from such people’s skills and experience, but changes to immigration policy that support the particular needs of Scotland.

I commend members’ contributions to the debate and am happy to discuss the matter at any time. I look forward to receiving support for our amendment.

15:46  

This has been an excellent debate, with well-informed and passionate contributions from across the chamber.

Many members, including Alex Rowley, Jackie Baillie and Alex Neil, made powerful statements about the reality of social care by providing vivid examples of vulnerable constituents, many of whom rely on unpaid carers—the backbone of our social care network.

I suspect that few members would disagree with the change in philosophy from hospital-based care to community-based health and social care. The key is to have a health and social care system that is based on human rights, in which people receive care based on need and not on the ability to pay.

As we have heard in the debate, we have several key challenges, including the high levels of turnover in the social care sector, which are exacerbated by low pay and the uncertainties of Brexit. By 2035, a quarter of Scotland’s population will be aged 65 or over, which is an increase of nearly one fifth since 2010. Just over one third of over 85-year-olds received care at home or as a long-stay resident in a care home, hospital—

Will the member take an intervention?

I am sorry, but I do not have enough time.

As we would expect, older people are more likely than younger people to be admitted to hospital in an emergency and to have multiple and complex needs.

Let us not forget that there are 657,000 unpaid carers in Scotland, half of whom are aged over 65.

Technology and innovation are also crucial. The Health and Sport Committee, of which I am a member, published an excellent report on the subject earlier this year. The report says that technology

“presents an opportunity to ensure innovation in health and social care flourishes and that Scotland is a leader and is not left behind.”

I will give an example. In my Highlands and Islands region, the Inverness city region deal is developing a very imaginative project called fit homes. The homes are future proofed to adapt to changes in residents’ mobility and have a series of sensors that collect data that can be monitored and responded to by, for example, health and housing agencies. The model is designed to create a viable, lower-cost alternative to full-time residential care and prolonged stays in hospital. I hope that that best practice will be picked up across Scotland.

Of course, it is a truism to say that good homes support good health, but I believe that that project could allow people to live independently in their communities for longer, which is very much the point that Alex Neil made in his insightful contribution.

The fit homes project is being developed by Carbon Dynamic in conjunction with Albyn Housing Society and NHS Scotland, and I am delighted to say that it landed the Saltire award.

I am constrained by time so I apologise to those whose contributions to the debate I am not able to mention.

Alex Rowley made an excellent speech about the treatment of social care workers. He quoted Enable Scotland, which I, in turn, will also quote. It says:

“The Joseph Rowntree Foundation reported in 2016 that 15% of the social care workforce are in in-work poverty. This means that we have Scotland’s most vulnerable people being cared for by Scotland’s most vulnerable workforce.”

He went on to talk about the differential rates of pay and conditions that care workers experience, and I highlight to all members the excellent Unison study and survey of the area.

Miles Briggs made a useful point when he talked about delayed discharge being a key factor; he said that the problem is getting worse. I also endorse his comments about social care internships as a factor in trying to reverse the problem of recruitment. Alison Johnstone made a useful point about the important role that unpaid carers play in Scotland, and Willie Rennie’s comment about 500,000 lost bed days per year was insightful.

Social care is the very heart of our welfare state. It embodies the Beveridge principles that created the system of welfare protection that looks after our vulnerable, our ill, our old and our sick. However, as Alex Rowley said, we need a significant shift in resources for social care services so that we can achieve a sustainable financial model and provide long-term stability for health and social care in Scotland. To conclude—on time—I note that the famous American anthropologist Margaret Mead once said:

“Never believe that a few caring people can’t change the world. For, indeed, that’s all who ever have.”