National Care Service (Scotland) Bill (Detailed)

The Bill does not provide sufficient detail to enable the Argyll & Bute HSCP/IJB to respond to this question.
The Bill does not confirm the scope and geographical remit of the new Board which will have responsibility for ensuring that the quality and consistency of services are improved for the communities it will serve.
We have a strong view that there should be a distinct Board serving the Argyll and Bute area (as defined within the current council boundary). This will ensure that the very specific needs of the rural and Island communities we currently serve are understood and met.
We do acknowledge that there is scope for improvement in respect of the integration and co-production and collaboration of services delivered in the area with our stakeholders and partners and across boundaries into Greater Glasgow and Clyde.
The Argyll and Bute HSCP is of the view that the implementation of the NCS has the potential to achieve the stated purposes and is optimistic that it will do so if it is properly resourced and the way in which it is structured is appropriate for the area. These resources should include capital funding and the transfer of property including equipment and IT. The structure, governance and accountability arrangements require to be sufficiently local to enable this to work effectively.
As one of only two IJB’s with all health and social care services delegated we would recommend maintenance of the status quo of delegated services – specifically children, families and justice during any interim arrangements.
The Bill references in principle standards for community health, social care and social work but provides not information on the achievement and review of training, potential for developed and integrated roles or cognisance of the time it would take to feel an impact on a cultural change in approach. It presents the bill in an environment of ‘status quo’ and risks negating gains made in practice through current integration arrangements.

As above, the Bill in itself does not provide sufficient detail on structures local or centralised, services or resourcing to enable a view to be taken.
It should be recognised that the costs of implementing the NCS are substantial. Resources that could have been allocated to service delivery within the existing model will be invested in significant structural change which will take many years to deliver benefits to service users.
The impact on employment terms as staff transfer to the new board could also prove to be extremely disruptive and costly.
Throughout the Bill there is recognition of the crucial involvement of people with lived experience and unpaid carers. The involvement of front line staff with a wealth of experience needs to be heard and engaged in order to improve the quality of consistency of service. At the heart of most of the social care and social work challenges are financial and workforce challenges both within HSCPs and with externally commissioned providers. Morale of the sector is low, harnessing front line staff knowledge and engaging effectively with this group is essential to the success of the NCS.
A review of opportunities and support into professions and available roles and training are integral to the development of the service and little mention is made of a supporting structure for this on the measuring of standards as an output.

There are some concerns that the unpaid carer right to a short break involves the removal of any eligibility criteria. Whilst we fully recognise the role of unpaid carers the resources to offer short breaks with no funding limitations is concerning, this needs clarified. It is not clear if legislation will be amended.
Given the IRASC had a focus on social care, the detail on the social work function and the identification of this crucial role is light. Social work and social care need to be identified as distinct and unique roles. The lack of certainty on employment also creates unease for all potentially affected staff when workforce presents a strategic risk nationally.

The Bill has actually raised more questions than it answers and the lack of detail leaves huge uncertainty. As such the Bill could be detrimental to service development and continuity.
Consideration for Children, Families & Justice Services which are currently integrated (as in in Argyll & Bute). As noted previously we would make a recommendation of maintaining the status quo during any interim arrangements to minimise disruption.

The commitment to local accountability and decision making is welcome, however, intentions around the number of Boards, their governance structures and geographical coverage should have been outlined at this stage to enable better informed consultation on the primary legislation. The HSCP would like to see this started or the process to be adopted included in primary legislation with a timescale to better inform the public during consultation.
The Bill gives the minister a wide range of new powers but this in itself does not enable an understanding of if or how these powers are intended to be used or the evidence base for decision making. This potentially results in less scrutiny at later stages and presents an increased risk of unintended local consequences.
The legislation goes further than to recommend a national care service as an abstract entity but not far enough to reflect what that would look like at national and local levels. It takes no account of the public duties currently assigned or assigned through participation in partnership to HSCP’s/IJB’s and partners which would be impacted.

The priority should be to ensure that the way in which the National Care Service operates and the powers transferred promote further integration of services and do not unintentionally undo progress that has been made to date.
There should also be some scope for local and rural variation and flexibility where this makes sense in the overall framework of integrated health and social care provision (without undermining the consistency objective). This is particularly relevant in rural and island communities which will often require tailored and pragmatic approaches to service delivery which can be very different to the way in which services are delivered and governed in urban areas.
Responsibility and funding for assets and infrastructure should be passed to the new Care Boards, noting that any transfer of assets may require funding to address existing estate issues.
A capital investment funding model requires to be a priority and should be based on the condition and suitability of the current infrastructure in each area. This is critical in ensuring that a single organisation has responsibility for both the services it provides and the physical assets and infrastructure used to provide those services.
The bill segregates community, acute and primary care provision taking no cognisance of the interdependent relationship, the agenda for preventative care in this context and the benefits gained in rural integrated care both in general working and in the support of clinical and care practice.
We believe local accountability is essential to meet the needs and priorities of the communities across Scotland. In our original response to the NCS consultation a hybrid model was proposed with clear lines of dual accountability. This model remains our preferred approach.
It is our view that Government should build on the success of IJBs, empowering them to operate independently. The Chief Officer role should be changed to that of a Chief Executive Officer. A directly funded and empowered IJB led by a CEO who would be accountable for the local delivery of social care. Working with the community to determine local priorities and the required investment.
Scottish Ministers would then hold the accountability for national decisions made which impact/influence the delivery of social care.

The Social Care sector in particular has been underfunded for many years. Within Argyll and Bute specifically there has been a significant lack of capital investment. This requires to be addressed by the NCS as a priority.
The development of a new, equitable funding model which takes cognisance of rurality, deprivation, demographics and the inherited asset base must be a priority if the NCS is to deliver on its objectives within a reasonable time horizon. Funding to the sector will require to be above the level it is at currently.
The implementation of the Bill will result in significant disruption and structural change, the scale of this is not yet clear. It is evidenced that this scale of change will likely result in increased governance and management costs so risks and impact can be effectively mitigated. This needs to be funded in addition to increased funding for service pressures and capital investment. Again the nature of the new Care Boards and the geographical areas they cover will have an impact on the scale and cost associated with the change.
There is a concern that local long standing partnerships will come under pressure whilst the NCS is created and that this in turn could result in additional local costs and challenges which are unforeseen in the context of the drafting of the legislation.
HSCPs in particular should be allocated relatively modest specific additional funding as soon as possible to fund the programme and project management of this significant management of change programme.
Health and Social Care services and systems are under considerable pressure and HSCPs should not be expected to begin this planning process from within existing resources. Change management lessons from other recent public sector reform process should be carefully considered.
No cognisance has been taken of the prolonged period of change in establishing integrated care services and a proposed period of further change within the bill. The unpicking of services whilst facing significant workforce and workforce planning pressures is poorly timed and may impede any potential benefit of a national approach.

The EQIA reflects where public bodies require to meet the duties currently and identifies no group covered under the PSED would be adversely affected by the legislation. It further notes the disparate picture in respect of the integration of children’s services. The interim EQIA fails to look at the wider societal picture of meeting the needs of communities within their communities, existence of communities of interest and infrastructures for supporting a truly equal approach to service provision outwith a metropolitan/urban environment. We would welcome a review of this document to better reflect the complexity of non-urban and mixed environments and consideration of where identity and lifelong conditions can result in direct or indirect discrimination.
Business and Regulatory impact assessment
Financial resources which are available may not necessarily lead to need being met e.g. the reference to short break to unpaid carers. Without the resolution of longer term workforce issues including infrastructure and affordable we would be unable to fulfil the policy directive.
Trade Unions have noted they will offer direct responses but note numerous issues in relation to structures, terms and conditions and ethical commissioning of services and private sector provision.
Child rights and wellbeing impact assessment
Integration of Children’s services has offered a the potential for a whole system approach supporting links from pre-birth through to transitions and continuity if adult care is required. At this stage of integration relevant authorities may only be starting to see the benefit and capacity available in delivering a planned approach which encompasses other key services such as Education, policing and third sector in supporting families.
Data protection impact assessment
The HSCP welcomes the creation of a nationally-consistent, integrated and accessible electronic social care and health record and recognises the importance and value and need for data protection. We welcome the DPIA noting that the data strategy focuses on 3 key areas as below:
Personal Data Stores- Personal web spaces, on our phones, breaking down data silo’s, able to access own health data , remove duplication of data, “a single version of the truth” remove the need to repeat the same information to different professionals involved in their care, within both social and health care effective use of “Application Programming Interface”
Managing Public Health- learn from pandemic response- public accessing data regarding Covid 19, future dashboard design
Data From Wearables- use of technology phones ,watches etc- BP monitoring, steps, blood O2, sleep, heart rate, mood –how we effectively use this personal data to support health and wellbeing
Fairer Scotland duty assessment
Unpaid Carers in a remote and island environment are often isolated through their caring role and have a burden of further isolation due to infrastructure , impact of weather conditions, unemployment or underemployment due to lack of opportunities. The Carers Act states the rights of carers and any potential move to an improved position requires to review the underpinning features of rural life to enable those rights to be exercised. There is no focus on the additional issues which are experienced in geographical areas with diverse community need.
The proposed National Care Service does not appear to recognise the part played by the unpaid carer in the overall provision of social care. The unpaid carer is a vital element of the overall provision of care in the community and without the unpaid carer a significant extra burden and cost would be placed on the overall provision of social care in all areas. There is a significant lack of understanding in the role provided by the unpaid carer and the responsibility the carer undertakes in respect of their cared for person. There is no easy way of defining the role of the unpaid carer, each case is different with a unique level of responsibility, commitment and stress. It is also a fact that in some cases becoming an unpaid carer is a life changing situation for the carer that may last for several years, while in other situations it is a short-lived experience. In many cases the unpaid carer has a 24 hour seven days a week commitment without any form of relief. Without the opportunity to have regular breaks the health of the carer can be impaired, which in turn impose an additional burden upon the health services. Overall the responsibilities undertaken by the unpaid carer reduces the demand on the social care and health services.
Island communities impact assessment
Do you have any comments on the contents and conclusions of these impact assessments or about the potential impact of the Bill on specific groups or sectors?
The island communities’ impact assessment lacks any intelligence on the reality of accessing health and social care services and the models of delivery especially in small communities with small health and social care infrastructures permanently on the island. Health and social care staff can have interchangeable roles at a certain level ensuring the safety of the most vulnerable. Whilst it is understood that a proportionate service should be offered with a safe and cohesive pathway to accessing acute care
As noted during online engagement sessions the impact assessments are currently very ‘light’ with particular reference to Island Communities. Response so far is that there will be an opportunity to develop this further – it would be more effective for parliament to review the principle of the Bill with a wider scope of information to fully evaluate the impact of the proposed change. It notes very little on the details of a potentially centralised service and the economic impact rurally further compounding access to a working age population and de-population in Argyll & Bute. In effect then we see no reference to the fulfilling rural growth and the maintenance of the infrastructure which supports a healthy workforce and promotes health equality.

Yes, the Argyll & Bute HSCP and IJB took part in the consultation process and made high level comment on the financial implications only as the consultation did not provide any financial detail at that time.

To a degree, however there is insufficient information, particularly relating to the number of new Care Boards and geography. It is also unclear which corporate or overhead costs would sit with the NCS centrally or would sit with the new Boards. This is important and provides an opportunity to develop a new joined up digital infrastructure for example could reduce local costs.

No – insufficient detail and time has been provided to enable a well considered response to be developed. The change being outlined is significant and will have many unintended consequences throughout Scotland due to the complex nature of existing and proposed future structures and service delivery models.

The bill will have financial implications for Health & Social Care services in Argyll & Bute. These are described in the Financial Memorandum in high level indicative terms only. Again the number of new Boards is important as is the range of corporate functions each one will need to support. It is critical that a new funding model which takes appropriate cognisance of the additional costs and inherent relative inefficiency of service delivery in remote and rural areas is absolutely essential if the objectives are to be met in our area. Again additional capital investment must also be a priority where investment in infrastructure has been lacking.

It is difficult to provide comments on this as the costs are in wide ranges and based on very high level assumptions. It is also unclear the extent to which the operation of the new Boards would be supported by central services and ICT systems and infrastructure. Overall the financial estimates appear broadly reasonable in this context. However, achieving savings will be particularly difficult in the transitional stages as it appears envisaged that costs (and therefore people, contracts, assets and services) will transfer from Local Authorities to the new Boards. This process is likely to be challenging and has the potential to result in additional costs and duplication rather than savings if existing partnership and co-location models start to break down during the transition process. It also has the potential to destabilise local authorities financially. Additionally the figures will require to be uplifted for higher than forecast inflation. Affordability should be reconsidered in the context of the challenges now facing public finances, these have clearly increased in recent weeks.

No. Specific central funding is required to enable IJB’s to transition into the NCS arrangements. This is recognised in the financial memorandum but difficult to quantify more accurately until there is further clarity. It is important that early resourcing is provided to enable the development of local project planning methodologies. The scale of the change and managing the impact on existing partnerships are critical to the overall project and this needs to be resourced as a relatively short term priority, the success of the project depends on this.
Technical issues such as those relating to VAT also need to be addressed and additional funding provided if necessary.

Earlier funding to IJB’s and more detail is required to accurately comment. Availability of workforce to manage and implement the change and practical transitional issues are likely to make it difficult to achieve the timescales and are likely to result in higher than anticipated costs (e.g. transitioning digital systems, contracts, direct and indirect staff, policies, procedures etc.). These costs and difficulties will vary depending on how closely the new Care Boards align with existing IJB’s.

The implication that the new Boards will be public bodies and not able to hold or generate reserves for investment could present a significant issue if they are also not able to borrow and there is insufficient capital funding available to enable current investment plans to progress.
The opportunity cost of the project could be substantial and will divert valuable management resource away from service delivery and transformation, this is particularly important in the context of the levels of service demand and workforce pressures currently being experienced.

We believe local accountability is essential to meet the needs and priorities of the communities across Scotland. In our original response to the NCS consultation a hybrid model was proposed with clear lines of dual accountability. This model remains our preferred approach.
It is our view that Government should build on the success of IJBs, empowering them to operate independently. The Chief Officer role should be changed to that of a Chief Executive Officer. A directly funded and empowered IJB led by a CEO who would be accountable for the local delivery of social care. Working with the community to determine local priorities and the required investment.
Scottish Ministers would then hold the accountability for national decisions made which impact/influence the delivery of social care.

The implementation of the Bill will result in significant disruption and structural change, the scale of this is not yet clear. It is evidenced that this scale of change will likely result in increased governance and management costs so risks and impact can be effectively mitigated. This needs to be funded in addition to increased funding for service pressures and capital investment. Again the nature of the new Care Boards and the geographical areas they cover will have an impact on the scale and cost associated with the change.

We believe local accountability is essential to meet the needs and priorities of the communities across Scotland. In our original response to the NCS consultation a hybrid model was proposed with clear lines of dual accountability. This model remains our preferred approach.
It is our view that Government should build on the success of IJBs, empowering them to operate independently. The Chief Officer role should be changed to that of a Chief Executive Officer. A directly funded and empowered IJB led by a CEO who would be accountable for the local delivery of social care. Working with the community to determine local priorities and the required investment.

This reflects current Strategic Planning and commissioning approach within the IJB. We would see to ensure we take a best practice and ethical approach to commissioning working with communities.

Supported

Supported

The current complaints system does not lend well to the integrated approach and an episode of care may straddle both health and social care services. Any effort to streamline the approach to complaints and ensuring it is easier for complainants to resolve any issues. However complaints are often better resolved closer to the operational source where the issues occurred and indeed where they can be addressed, learned from and rectified.

The Bill references both structural reform to improve on the ground services and a centralised and supervised approach by ministers to intervene as required. This response references the importance of local accountability, financial accountability and indeed this is reflected further in the submission from Chief Financial Officers. Ministerial oversight may bring benefit in setting a direction for change and enabling this but may do little to change the ongoing risks held by IJB's which are consistent across Scotland in respect of infrastructure, affordable housing and workforce availability.

Response is reflected in relation to the financial memorandum in terms of powers delegated to the proposed Care Boards

The Bill provides little detail beyond the establishment of powers with little cognisance taken on the breadth of the current structure in place through integration schemes.

Argyll & Bute has all health and social care services delegated within its scheme of delegation and there is a recommendation that during interim arrangements the status quo of the scheme can be upheld.

As noted previously responsibility and funding for assets and infrastructure should be passed to the new Care Boards, noting that any transfer of assets may require funding to address existing issues.

A capital investment funding model requires to be a priority and should be based on the condition and suitability of the current infrastructure in each area. This is critical in ensuring that a single organisation has responsibility for both the services it provides and the physical assets and infrastructure used to provide those services.

The Bill does not make reference to supporting services of which the IJB as a non-employing body has none.

Integration of Children’s services has offered the potential for a whole system approach supporting links from pre-birth through to transitions and continuity if adult care is required. At this stage of integration relevant authorities may only be starting to see the benefit and capacity available in delivering a planned approach which encompasses other key services such as Education, policing and third sector in supporting families.

As a fully integrated IJB there are forecast impacts in not considering childrens services and justice and this response has noted a recommendation to maintain the status quo if the bill consults separately on this matter.

A shared approach would bring significant benefit to both staff and people using services. Any interim arrangement would require to take cognisance of a very complex landscape of supporting systems and the importance of cyber resilience.

There are some concerns that the unpaid carer right to a short break involves the removal of any eligibility criteria. Whilst we fully recognise the role of unpaid carers the resources to offer short breaks with no funding limitations is concerning, this needs clarified. It is not clear if legislation will be amended.

Supported

Implications of this aspect of the Bill should potentially be explored further. Centralised contracting can be problematic for remote and rural communities.

The IJB recognise the need for development and support, social care reform and investment but the Bill does not specify how it will achieve this beyond the stated vision and principles.