About you
3. What is your name?
Name
(Required)
Catriona Melville
5. Are you responding as an individual or on behalf of an organisation?
Organisation
Age Scotland
Budget context
6. How would you see these planned budget increases meeting the various challenges facing health and social care over the next four years, including: addressing the treatment backlog; the planned creation of a National Care Service; cost and demand pressures in areas such as NHS pay, drug costs and demographic pressures?
Please provide your response in the box provided.
Age Scotland welcomes the opportunity to respond to the Committee’s pre-budget scrutiny consultation. Our NHS and social care systems are under extreme pressure and will continue to face high levels of demand in light of our ageing population. Our growing older population must be able to live independently and well for as long as possible with access to high quality health and social care to support them to do so. To do this, there must be a whole systems approach in place, across both health and social care, which must in turn be sufficiently resourced. Ensuring proactive and preventative healthcare must be a focus, including that which is joined up to sources of support in the community.
It is welcome that the Scottish Government has committed to 4% real terms increases for health and social care over the next four years. However, it is unclear if this will go far enough to deal with many of the pressures facing the sector and the demands for funding of the National Care Service and fair pay deals for workers. It is clear the NHS and social care services will need to make efficiency improvements in order to safeguard frontline care.
It is well understood that Scotland’s health and social care system is facing numerous challenges – including ongoing recovery from the Covid-19 pandemic, delayed discharge, waiting times for social care assessments, and staffing and recruitment issues across the NHS and social care. During our engagement surrounding the Scottish Government’s proposed Health and Social Care Strategy for Older People (the development and implementation of which has since been postponed as the decision was taken to link it to the forthcoming National Care service) last year, we encountered feelings of anger, frustration, and even despair over the state of healthcare system among the older people we spoke to.(1) Many believed that healthcare services have gotten worse over the past few years and are likely to continue to deteriorate. Waiting times came up again and again during these conversations with regards to diagnosis, check-up appointments, scans, operations, and treatment, during which time conditions worsened or progressed, potentially even becoming untreatable or less treatable than if services had been provided earlier. People gave examples of waiting two or three years for operations or treatment, being left in pain and without recourse to suitable support in the meantime. There were numerous examples of people turning to private healthcare services to avoid long waits and cancellations. People also knew of others who have had to borrow money from family or friends or put their future financial stability at risk by using up savings to afford private treatment out of desperation.
Demand for health and care services will rise sharply in coming years as our population ages. By 2045, almost 50% of the Scottish population will be over 50 and the number of people aged 65 and over is projected to grow by almost one third.(2) This is significant as currently 46% of those over 65 and 60% of those over 75 have a limiting long-term condition.(3) Additionally, people over 70 are thought to live with an average of three health conditions. Therefore, the NHS and social care system will be catering to a population which might be living for longer but in poorer overall health.
These demographic changes will also have implications for the NHS and social care workforce. While the number of over 65s is increasing, the working age population is expected to remain broadly stable, but the population will fall overall as less children are born. These demographic changes must be central to workforce planning in these sectors. There are an estimated 146,600 over 50s (38.6% of all employees within the sector) working in “health and social work”.(4) It is important that older workers are supported in the workplace and feel valued by colleagues and managers. When these skilled and experienced workers leave (for instance, when retiring), there may be a gap in the workforce unless sufficient legacy planning and workforce capacity building efforts are put in place. Planning to avoid this should consider how to ensure there are not staff shortages in the long-term, but also how the workforce is equipped to meet the needs of our growing older population. Staffing shortages, which are already an issue, will become even more vital to tackle in the wake of ever-increasing demand as our population lives for longer and often with multiple long-term health conditions. We need the right workforce, with the right skills, working in the right places to deliver efficient and effective services.
Older people regularly tell us that social care is not meeting their needs, which is having a profound impact on the outcomes they experience and their quality of life. Social care is of vital importance, and it was a priority issue for the over 4,000 respondents to our Big Survey 2023.(5) Many older people face long waits to access assessments, services, and care packages. The increased demand for social care in turn places pressure on demand for support in the community. Social care requires urgent reform, and it must be given the resources and status it needs to deliver for those who use it now and in the future. As Audit Scotland and the Accounts Commission have previously highlighted, although significant funding is allocated to social care, “progress in moving to more preventative approaches to delivering social care has been limited”.(6) They suggest this has meant stricter eligibility criteria are being applied for accessing care, resulting in higher levels of unmet need. Currently, the dedication of social care staff is not matched by value and recognition, which are lacking, and pay and working conditions, which are poor. For social care reform to be successful, there must be a sustainable care workforce and appropriate workforce planning. One of the key concerns regarding social care is the perception that the system is fragmented, with separate parts and services not working well together and lack of coordination between agencies. Efforts to reform social care cannot be put on hold, and the Scottish Government must progress its plans for reform and recovery as a matter of urgency. Older and disabled people cannot wait for a National Care Service – they need the care services which are their right now. The National Care Service has been paused but already the consultancy and staffing cost of setting it up is mounting and there is yet to be clarity provided through the revised Financial Memorandum on what the service will cost when it is operational. While we welcome the Scottish Government’s commitment to listen to people with lived experience and stakeholders throughout public meetings this summer, change cannot come soon enough for service users. To support this, we urgently need more recruitment and long-term, sustainable, investment in social care to help cope with the growing demands of an ageing population and ensure better integration between services.
(1) Age Scotland response to Health and Social Care Strategy for Older People (2022) https://www.ageuk.org.uk/globalassets/age-scotland/documents/politics-and-government/consultation-responses/2022-pdf/agesco~1.pdf
(2) Calculations based on National Records of Scotland 2020-based population projections (2022) https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-projections/population-projections-scotland/2020-based
(3) The Scottish Health Survey 2021 - volume 1: main report (2022) https://www.gov.scot/publications/scottish-health-survey-2021-volume-1-main-report/pages/6/
(4) Scotland's Labour Market: People, Places and Regions - Statistics from the Annual Population Survey 2020/21 https://www.gov.scot/publications/scotlands-labour-market-people-places-regions-statistics-annual-population-survey-2020-21/
(5) We expect to publish the full findings of our Big Survey 2023 in September
(6) Audit Scotland and Accounts Commission, Social Care briefing, (2022) https://www.audit-scotland.gov.uk/uploads/docs/report/2022/briefing_220127_social_care.pdf
It is welcome that the Scottish Government has committed to 4% real terms increases for health and social care over the next four years. However, it is unclear if this will go far enough to deal with many of the pressures facing the sector and the demands for funding of the National Care Service and fair pay deals for workers. It is clear the NHS and social care services will need to make efficiency improvements in order to safeguard frontline care.
It is well understood that Scotland’s health and social care system is facing numerous challenges – including ongoing recovery from the Covid-19 pandemic, delayed discharge, waiting times for social care assessments, and staffing and recruitment issues across the NHS and social care. During our engagement surrounding the Scottish Government’s proposed Health and Social Care Strategy for Older People (the development and implementation of which has since been postponed as the decision was taken to link it to the forthcoming National Care service) last year, we encountered feelings of anger, frustration, and even despair over the state of healthcare system among the older people we spoke to.(1) Many believed that healthcare services have gotten worse over the past few years and are likely to continue to deteriorate. Waiting times came up again and again during these conversations with regards to diagnosis, check-up appointments, scans, operations, and treatment, during which time conditions worsened or progressed, potentially even becoming untreatable or less treatable than if services had been provided earlier. People gave examples of waiting two or three years for operations or treatment, being left in pain and without recourse to suitable support in the meantime. There were numerous examples of people turning to private healthcare services to avoid long waits and cancellations. People also knew of others who have had to borrow money from family or friends or put their future financial stability at risk by using up savings to afford private treatment out of desperation.
Demand for health and care services will rise sharply in coming years as our population ages. By 2045, almost 50% of the Scottish population will be over 50 and the number of people aged 65 and over is projected to grow by almost one third.(2) This is significant as currently 46% of those over 65 and 60% of those over 75 have a limiting long-term condition.(3) Additionally, people over 70 are thought to live with an average of three health conditions. Therefore, the NHS and social care system will be catering to a population which might be living for longer but in poorer overall health.
These demographic changes will also have implications for the NHS and social care workforce. While the number of over 65s is increasing, the working age population is expected to remain broadly stable, but the population will fall overall as less children are born. These demographic changes must be central to workforce planning in these sectors. There are an estimated 146,600 over 50s (38.6% of all employees within the sector) working in “health and social work”.(4) It is important that older workers are supported in the workplace and feel valued by colleagues and managers. When these skilled and experienced workers leave (for instance, when retiring), there may be a gap in the workforce unless sufficient legacy planning and workforce capacity building efforts are put in place. Planning to avoid this should consider how to ensure there are not staff shortages in the long-term, but also how the workforce is equipped to meet the needs of our growing older population. Staffing shortages, which are already an issue, will become even more vital to tackle in the wake of ever-increasing demand as our population lives for longer and often with multiple long-term health conditions. We need the right workforce, with the right skills, working in the right places to deliver efficient and effective services.
Older people regularly tell us that social care is not meeting their needs, which is having a profound impact on the outcomes they experience and their quality of life. Social care is of vital importance, and it was a priority issue for the over 4,000 respondents to our Big Survey 2023.(5) Many older people face long waits to access assessments, services, and care packages. The increased demand for social care in turn places pressure on demand for support in the community. Social care requires urgent reform, and it must be given the resources and status it needs to deliver for those who use it now and in the future. As Audit Scotland and the Accounts Commission have previously highlighted, although significant funding is allocated to social care, “progress in moving to more preventative approaches to delivering social care has been limited”.(6) They suggest this has meant stricter eligibility criteria are being applied for accessing care, resulting in higher levels of unmet need. Currently, the dedication of social care staff is not matched by value and recognition, which are lacking, and pay and working conditions, which are poor. For social care reform to be successful, there must be a sustainable care workforce and appropriate workforce planning. One of the key concerns regarding social care is the perception that the system is fragmented, with separate parts and services not working well together and lack of coordination between agencies. Efforts to reform social care cannot be put on hold, and the Scottish Government must progress its plans for reform and recovery as a matter of urgency. Older and disabled people cannot wait for a National Care Service – they need the care services which are their right now. The National Care Service has been paused but already the consultancy and staffing cost of setting it up is mounting and there is yet to be clarity provided through the revised Financial Memorandum on what the service will cost when it is operational. While we welcome the Scottish Government’s commitment to listen to people with lived experience and stakeholders throughout public meetings this summer, change cannot come soon enough for service users. To support this, we urgently need more recruitment and long-term, sustainable, investment in social care to help cope with the growing demands of an ageing population and ensure better integration between services.
(1) Age Scotland response to Health and Social Care Strategy for Older People (2022) https://www.ageuk.org.uk/globalassets/age-scotland/documents/politics-and-government/consultation-responses/2022-pdf/agesco~1.pdf
(2) Calculations based on National Records of Scotland 2020-based population projections (2022) https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-projections/population-projections-scotland/2020-based
(3) The Scottish Health Survey 2021 - volume 1: main report (2022) https://www.gov.scot/publications/scottish-health-survey-2021-volume-1-main-report/pages/6/
(4) Scotland's Labour Market: People, Places and Regions - Statistics from the Annual Population Survey 2020/21 https://www.gov.scot/publications/scotlands-labour-market-people-places-regions-statistics-annual-population-survey-2020-21/
(5) We expect to publish the full findings of our Big Survey 2023 in September
(6) Audit Scotland and Accounts Commission, Social Care briefing, (2022) https://www.audit-scotland.gov.uk/uploads/docs/report/2022/briefing_220127_social_care.pdf
Longer-term outlook
7. Given the short-term and immediate pressures on the health and social care system, how can the Scottish Government take the more radical decisions required around service redesign, or reducing/stopping existing services?
Please provide your response in the box provided.
It is clear that services must adapt in order to cope with the challenges they face. However, this should always be in a way which does not further disadvantage minorities or groups with protected characteristics.
The centralisation of services and more limited use of smaller local hospitals is often highlighted to Age Scotland as a barrier for older people’s ability to access medical services, particularly those in more rural or remote locations, and including where large amounts of money have been used to resource smaller and more local settings in recent memory. During our engagement surrounding the Health and Social Care Strategy for Older People last year, we heard that many local services which previously worked well for people, increasing ease and significantly reducing travel time, have been closed or scaled back. There was a sense that people wanted to see the return of the delivery of more services at local health centres and community hospitals – something which may also emerge during the Committee’s upcoming inquiry regarding healthcare in remote and rural areas.
Moving to digital-only services is a frequently identified barrier to accessing services highlighted by older people. Up to 500,000 over 50s in Scotland do not have access to the internet, and there are up to 600,000 over 50s without a smart phone. While for some people, this is a choice which should be respected, for others this may be because they live in an area with poor connectivity, because they don’t feel they have the confidence or skills needed, or because they cannot afford the cost of broadband. Further, there are many more people that do have access to technology but are not comfortable or not able to use it to access services. Only two thirds of internet users who responded to our Big Survey 2023 described themselves as confident or very confident in using the internet and navigating online services. While for some, digital appointments have proved convenient and work well, for others, they do not work at all and compromise on the level of care received. Offering appointments on a digital only basis is inappropriate for those who do not have devices or who are not comfortable using them for video appointments. 82% of Big Survey 2023 respondents preferred an in-person GP appointment whilst 10% preferred a telephone call and 1% a video call. Older people, and indeed all patients, must be able to access the healthcare they need, when they need it – and have a choice in how they do so.
The centralisation of services and more limited use of smaller local hospitals is often highlighted to Age Scotland as a barrier for older people’s ability to access medical services, particularly those in more rural or remote locations, and including where large amounts of money have been used to resource smaller and more local settings in recent memory. During our engagement surrounding the Health and Social Care Strategy for Older People last year, we heard that many local services which previously worked well for people, increasing ease and significantly reducing travel time, have been closed or scaled back. There was a sense that people wanted to see the return of the delivery of more services at local health centres and community hospitals – something which may also emerge during the Committee’s upcoming inquiry regarding healthcare in remote and rural areas.
Moving to digital-only services is a frequently identified barrier to accessing services highlighted by older people. Up to 500,000 over 50s in Scotland do not have access to the internet, and there are up to 600,000 over 50s without a smart phone. While for some people, this is a choice which should be respected, for others this may be because they live in an area with poor connectivity, because they don’t feel they have the confidence or skills needed, or because they cannot afford the cost of broadband. Further, there are many more people that do have access to technology but are not comfortable or not able to use it to access services. Only two thirds of internet users who responded to our Big Survey 2023 described themselves as confident or very confident in using the internet and navigating online services. While for some, digital appointments have proved convenient and work well, for others, they do not work at all and compromise on the level of care received. Offering appointments on a digital only basis is inappropriate for those who do not have devices or who are not comfortable using them for video appointments. 82% of Big Survey 2023 respondents preferred an in-person GP appointment whilst 10% preferred a telephone call and 1% a video call. Older people, and indeed all patients, must be able to access the healthcare they need, when they need it – and have a choice in how they do so.
Financial Sustainability
10. How can or should any additional health and social care funding be directed to support alternative models of service delivery?
Please provide your response in the box provided.
Although falls can happen to anyone, they tend to have more of an impact and be more serious for those in later life. The latest figures for hospital admissions for unintentional injuries show that the rate of falls in those aged 65 and over has increased from 20.7 per 1,000 in 2012-13 to 22.5 per 1,000 in 2021-22.(7) Additionally, 87% of unintentional injuries in the over 65s were due to falls.(8) The most recent Scottish Hip Fracture Audit showed there were 1,000 more people attending hospital in 2022 with a fractured hip than pre-pandemic levels in 2019.(9) Our 2021 Big Survey highlighted the negative impact of the pandemic on mobility levels amongst older people – 64% of respondents were less active due to public health restrictions – but these figures underline the scale of the challenge the knock-on impact poses to NHS and social care services.(10) With some forward planning, falls can be prevented through various means including raising awareness, advocating strength and balance movement classes, and changes in our homes such as better lighting or a second handrail. Increasing the priority given to the falls prevention agenda, such as a robust falls prevention plan, will help to reduce the pressure these injuries place on the NHS and social care services.
Innovations such as Hospital at Home have the potential to fill gaps where other supporting services are limited and unable to match demand – for instance reducing the need for transport (including via an ambulance) to and from hospital. As Hospital at Home expands, there should be continued data capture about its effectiveness and impact, including cost benefits analysis, but also qualitative feedback from patients, their families, and carers, about their experiences.
Frontline third sector services are also contributing vastly to supporting people’s health and care needs. If the Scottish Government is serious about delivering strategies which prevent more expensive interventions downstream, like hospital admissions, comprehensive investment in support provided by third sector organisations is also needed. Our Keeping the Doors Open report explored the vital role of older people’s community groups and services.(11) This included tackling loneliness and social isolation, promoting health and wellbeing and allowing people to stay active, providing support and advice, and offering educational activities. Many groups were described as a “lifeline” for their members. The report also shed light on the unmanageable pressure is being placed on local community and voluntary groups and services to plug prominent gaps where public services fell short. As a result of the report, Age Scotland was awarded funding by the Scottish Government to deliver a “Keeping the Doors Open Fund” – we distributed £175,000 to member groups to allow them to do this. The importance of funding for older people’s groups cannot be overstated.
(7) Unintentional injuries Hospital admissions year ending 31 March 2022 and deaths year ending 31 December 2021 (2022) https://publichealthscotland.scot/publications/unintentional-injuries/unintentional-injuries-hospital-admissions-year-ending-31-march-2022-and-deaths-year-ending-31-december-2021
(8) Unintentional injuries Hospital admissions year ending 31 March 2022 and deaths year ending 31 December 2021 (2022) https://publichealthscotland.scot/publications/unintentional-injuries/unintentional-injuries-hospital-admissions-year-ending-31-march-2022-and-deaths-year-ending-31-december-2021
(9) Public Health Scotland, Scottish Hip Fracture Audit 2022 (2023) https://publichealthscotland.scot/publications/scottish-hip-fracture-audit/scottish-hip-fracture-audit-reporting-on-2022/
(10) Age Scotland, Big Survey (2021) https://www.ageuk.org.uk/globalassets/age-scotland/documents/policy-and-research/high-4967-scotinfrom-age-scotland-big-survey---full-report.pdf
(11) Age Scotland, Keeping the Doors Open: What do older people's community groups need to recover from the impact of Covid-19? (2022) https://www.age.scot/keepingthedoorsopen
Innovations such as Hospital at Home have the potential to fill gaps where other supporting services are limited and unable to match demand – for instance reducing the need for transport (including via an ambulance) to and from hospital. As Hospital at Home expands, there should be continued data capture about its effectiveness and impact, including cost benefits analysis, but also qualitative feedback from patients, their families, and carers, about their experiences.
Frontline third sector services are also contributing vastly to supporting people’s health and care needs. If the Scottish Government is serious about delivering strategies which prevent more expensive interventions downstream, like hospital admissions, comprehensive investment in support provided by third sector organisations is also needed. Our Keeping the Doors Open report explored the vital role of older people’s community groups and services.(11) This included tackling loneliness and social isolation, promoting health and wellbeing and allowing people to stay active, providing support and advice, and offering educational activities. Many groups were described as a “lifeline” for their members. The report also shed light on the unmanageable pressure is being placed on local community and voluntary groups and services to plug prominent gaps where public services fell short. As a result of the report, Age Scotland was awarded funding by the Scottish Government to deliver a “Keeping the Doors Open Fund” – we distributed £175,000 to member groups to allow them to do this. The importance of funding for older people’s groups cannot be overstated.
(7) Unintentional injuries Hospital admissions year ending 31 March 2022 and deaths year ending 31 December 2021 (2022) https://publichealthscotland.scot/publications/unintentional-injuries/unintentional-injuries-hospital-admissions-year-ending-31-march-2022-and-deaths-year-ending-31-december-2021
(8) Unintentional injuries Hospital admissions year ending 31 March 2022 and deaths year ending 31 December 2021 (2022) https://publichealthscotland.scot/publications/unintentional-injuries/unintentional-injuries-hospital-admissions-year-ending-31-march-2022-and-deaths-year-ending-31-december-2021
(9) Public Health Scotland, Scottish Hip Fracture Audit 2022 (2023) https://publichealthscotland.scot/publications/scottish-hip-fracture-audit/scottish-hip-fracture-audit-reporting-on-2022/
(10) Age Scotland, Big Survey (2021) https://www.ageuk.org.uk/globalassets/age-scotland/documents/policy-and-research/high-4967-scotinfrom-age-scotland-big-survey---full-report.pdf
(11) Age Scotland, Keeping the Doors Open: What do older people's community groups need to recover from the impact of Covid-19? (2022) https://www.age.scot/keepingthedoorsopen
Health and social care outcomes
11. How should health and social care budgets be prioritised in this landscape of multiple frameworks and targets and which targets or outcomes should take precedence?
Please provide your response in the box provided.
The Scottish Government had the opportunity to address and set out how it would tackle many of the challenges facing older people in both the health and social care spheres in the much-needed Health and Scotland Care Strategy for Older People but took the decision to delay the development and implementation of this strategy. As this is now tied to the forthcoming National Care Service, we are concerned it will get lost in the midst of other strategies and frameworks – despite its pressing and urgent importance.