In just over a week Scottish Care will be hosting our annual Care at Home Conference, Exhibition and Awards. It is shaping up to be a great day of debate, a very full exhibition and a real opportunity to celebrate the best of homecare across Scotland in the evening. The title of the event as a whole is ‘Redressing the balance: the potential of homecare.’ To some extent it is a bit disquieting and disappointing that we are still talking about re-dressing the balance of care in Scotland. After all we have had a policy direction of enabling independent living and support in our communities and homely settings for over two decades – and yet we are still talking about re-dressing the balance from acute to community, from health and clinical dominated concepts to social care practice, from time and task commissioning to relationship, trust-based approaches. To redress the balance means to achieve ‘an even distribution of weight to ensure equilibrium within a system.’ It is that care equilibrium that is significantly missing from our current approaches to health and social care in Scotland. That’s what we are after in social care – namely the gain of truly integrated services and supports which we are meant to achieve. At the heart of the debate and all the policy and political priorities in terms of re-dressing the balance is the need to move the focus from reactive response to need on to one which is truly preventative in nature. This is the massive and largely untapped potential of homecare within the whole health and social care system and economy. For what we are seeing in practice on the ground across Scotland is yet more sophisticated approaches to reacting after the horse has bolted. Our eligibility criteria which determine the level at which social care supports and services can be accessed have now reached critical in most parts of the country; and resources for innovation and new models of care are depleted and drained as we seek to keep the ship of care from grounding on the rocks of reality. As a sector with some of the best independent care and support, providers and frontline workers alike are straining under the stress of ever-growing demands being met from ever-tightening funding. It is the care economics of insanity not to recognise that we need to prevent people from accessing the expensive and unhealthy acute system in the first place rather than to seek to respond to their needs once they have been in it. Let us stop people from going to hospital after their latest bout of mental distress and illness; let us prevent unplanned admissions as a result of an unnecessary fall or incident; let us ensure that malnutrition and poor diet, unaddressed lifestyle factors and loneliness are not the vehicles for the inevitable journey into the acute system. But to achieve all that we have to change not just the rhetoric but the reality to properly resource our social care sector in order to enable real prevention to happen. It is not rocket science so why decades after policy initiatives are we still talking and not doing? There is a real opportunity for us to be brave and dynamic, innovative and creative in working together at local level, commissioners, planners and providers in developing models of preventative care which are up to the mark. We can do so much better than we are at present in developing models and approaches which prevent an individual from either early or unnecessary access to enhanced care, hospitalisation or sharper personal physical decline and deterioration. We can do so much better in working together to re-balance care so that we focus on approaches which enable independent living for a longer period of time and which focus on maintaining a higher quality of life and wellbeing. Our obsessive functionalist approach to social care is not only degrading and demeaning of worker and recipient alike, it is a public health hazard and threat. Let us work together to re-balance care by achieving the potential of care at home and housing support, by maximising autonomy and control. Join us on 17th May and get involved in the debate! Dr Donald Macaskill, CEO Scottish Care @DrDMacaskill

Putting human rights into the commissioning cycle

  This has been a period of uncertainty and deadlines. It seems every other headline covers Brexit, but for the care sector there is a real and significant effect of negotiation at various levels. When 19 care homes closed last year, and 9 out of 10 of our care at home providers told us that they may not survive until the end of the financial year, it confirmed that we are in worrying times indeed. The Freedom of Information request by Robert Kilgour on the cost of statutory care home provision highlighted that the cost for the Local Authority to run a care home is double that of what they pay the independent sector. We know that for care at home providers the proportionality is similar. But it is not simply about cost. The care sector is exactly that, a sector which cares. Choice and control is critical to the Self Directed Support Act and the independent care sector is sufficiently diverse to meet that; made up of charitable, voluntary and private providers; and they range from small, single, family-owned businesses through to large corporates. It is a vibrant sector, grounded in Human Rights and the National Health and Social Care Standards which enable person-led care and support in a flexible way. We know this from our conferences and awards ceremonies; held to facilitate innovation at the forefront of the sector, and to celebrate the dedicated but often overlooked staff with whom it is an honour to work. I am fortunate to have had a varied career in health and social care and have experienced the sector from many different perspectives. The intent of the system is to have the person at the centre, yet, there are glaring gaps and confusion. All too often commissioning (the delicate balance of facilitation and planning to ensure the right services are provided at the right time) is confused with procurement (the purchasing of services). With only one major purchaser – integrated authorities, the concept of competition in the sector is a false one, and the push to drive down costs has led to a focus on the wrong things. We measure the amount of time that we spend with a person, not what difference we made for that person during that time. This competition also limits opportunity for the collaboration needed to maximise the full potential of the sector and is worsened by the tendency to consider only one part of the system and not the totality as intended by the Public Bodies (Joint Working) Act on integration. Back when I was a Local Authority commissioner, the Commissioning Cycle was my guide as remains true for commissioners today; Plan, Do, Analyse, Review (repeat). But I came into that role with the experience of having been a carer, social worker, researcher and citizen. I knew that bringing those components and more to the table would change the nature of the process. So we changed the make up of the Board. It was, I now realise ‘integrated’; it consisted of 50% citizens and 50% professionals comprising of health, social care, commissioners, providers and procurement managers. This was over 10 years ago now and at the time it was not considered revolutionary, it was merely a step on the road to getting it right. Together, we could map a realistic picture of a complicated landscape, and create the conditions to share resources, maximising the potential of the totality of our assets, but most importantly, we could sense check this approach with those who matter. It took time and courage, but we created a safe space to try out new ideas, quickly focussing on successes, continually improving as we went, always coming back to the person. It is this realistic and person focussed embracement of the commissioning process which meant that the changes we made were meaningful and had impact; increasing the number of people who could access care and support by 110% at no extra cost, and with every one of them saying that the service had made a positive difference to them. The current frustrating focus on measuring outputs limits our possibilities, as do the invisible and enduring barriers of silo-working. But change takes bravery. We had to put in systems to support those involved in decision making to enable them to equally and fully participate in the process. At Scottish Care we do something similar for the independent sector through our Branch structure and Partners for Integration Team, representing our members, creating trusting relationships with our partners to enable collaboration. We have some great examples where working together has led to people getting the right support in the right place at the right time; implementing an enablement approach, supporting people to move back into the community, reducing falls and pressure ulcers to prevent admission to hospital, and targeting medicine waste to make tens of thousands of pounds worth of savings per month in just one area of Scotland. For all of these to work, they had to be approached with courage, and from the perspective of the person accessing care and support. Without this they would have failed. Planning and Review is all good and well, but what is clear in the current landscape of diminished budgets and increased need is that that we need to change our approach across Scotland. It is time to put human rights into the Commissioning Cycle.   Karen Hedge National Director, Scottish Care @hegeit  

On Wednesday 3^rd April the Scottish Government published ‘A Fairer Scotland for Older People: framework for action.’ Over a year after the creation of the first ever ministerial portfolio for Older People, the document is an important contribution to addressing the challenges facing Scotland’s older population. Sadly, despite what I would consider to be an excellent starting point this Framework report has received only a minimum amount of media coverage. You could say, of course, that Brexit and its shambles dominates the media. However, even without Brexit the absence of any significant media comment is perhaps itself illustrative of the challenges in addressing age apathy within our contemporary society. The Framework is a starting point. In her Ministerial Foreword Christina McKelvie MSP states that: ‘I am also aware that older people can be marginalised. Maybe that is because we fear ageing and the impacts it can have on our lives through deteriorating health or because, quite simply, ageing is something most of us don’t want to think about. ‘It is time to remove barriers, tackle inequalities and allow people to flourish and be themselves. That is why I am publishing this framework. It affirms our responsibility to ensuring equality for everyone as they age and outlines the clear steps, we will take to deliver improvement.’ She goes on to state: ‘Importantly, the framework provides a platform from which we can reframe our thinking about older people, to move from what can be a negative, problem-focused perspective to a positive and cohesive recognition of older people as a vital part of Scotland’s potential for success and improvement in the 21st century. ‘We recognise that change will not occur overnight and will require years of sustained effort and a change in thinking…Scotland’s older people today and those older people of tomorrow are depending on us to deliver.’ I would encourage you to read the document as it brings together in one place actions and priorities around older age and also indicates areas where there needs to be more work and where we need to start addressing the barriers that prevent older people from becoming full citizens. So why is this important? Well on a simple level – if we are to create a fair society then that society needs to be inclusive of all and enabling of all citizens to achieve to their fullest potential. Sadly, this is not always the case for older people especially given the definition of older person in the framework as anyone from age 50. There are too many cases of age discrimination whether that be in the workplace or in accessing services and resources. Scotland has an ageing population, and this is surely something to celebrate although all too often it is the subject of negativity or simple stereotype. The population is ageing at a faster rate in Scotland than the rest of the UK. Median age (the age at which half the population is older and half younger) in Scotland is 42.0 years from the mid-2017 population estimates, around two years higher than in the UK as a whole and is projected to rise to 45.4 years by 2041, compared to 43.5 years for the UK. There is also considerable geographical variation in the ageing of the population within Scotland. In general, it is lowest in the cities and higher in more rural areas. Between 2016 and 2026, all council areas in Scotland are projected to experience an increase in their population aged 75 and over. Clackmannanshire (+48.0%) and West Lothian (+46.0%) are projected to experience the largest increases, while Dundee City (+9.6%) and Glasgow City (+2.9%) have the smallest increases. Therefore we have a particular challenge in Scotland but that also gives us a real opportunity to ensure that Scotland is ‘the best place in the world to grow older.’ Age matters to all of us and most especially to those organisations who work in the care and support of older people in Scotland. Indeed, the Framework addresses some of the very real issues which the social care sector is currently facing in contemporary Scotland. It highlights the importance of social care in enabling older people to remain parts of their community, and to be active and contributing citizens. It addresses some of the challenges in ensuring that a career in care is viewed as a positive choice and that the standards and quality of care and support continue to improve. It requires the voice of older Scots to be at the heart of the decisions around the reform and future of social care and health. Yet the Framework also shows the distance we have to go. It challenges the discriminatory behaviours and attitudes which treat older age persons as less than those of other ages. It calls out behaviours which dismiss the contribution of those whose communication is changing and those who face frailty and ill health. Scottish Care has long argued that there is a profound discrimination at the heart of the way in which older people are treated within society. At a simple level discrimination is when one treats another on whatever basis in a less favourable manner than you would treat someone else. That discrimination happens to older Scots far too often up and down Scotland every day of the week. It is often so subtle and unconscious that it is almost impossible to recognise or name – but discrimination it is nevertheless. The Framework is an excellent starting point in the journey towards achieving the ability of older people in Scotland to exercise and enjoy their full rights and entitlements as citizens. It is a summative work describing existing commitments and future aspirations. The challenge is to ensure that it does not simply remain a summary of good intention but becomes the description of action-led response. There are still today too many instances in the social care of older persons where we are daily witnessing systemic discrimination in Scotland. Why are so few older people in Scotland actively and fully participating in the range of choices which are offered under the Self-directed Support Act? Why do I still hear social work assessors say ‘SDS is not for older people’? Why are there so few of the 33,000 people whose home is a care home who have been given an outcomes focussed assessment to determine their needs and wishes, who have been allocated a personal budget and given real choice rather than the fiction they are offered, all of which is their entitlement under the SDS Act? In terms of revenue and resource why does the social care sector have to fight a continual battle to maintain already inadequate resource allocation for vital services and supports? Despite being a major contributor to the Scottish economy why does the social care of older people in Scotland continually get described as a cost and a drain on our society? Why do those who live with dementia effectively pay twice for that care and support whereas those with other conditions do not? There are many instances where we have some distance to go to create a fair Scotland where everyone is enabled to exercise their human rights regardless of age. The Framework makes a helpful start. I for one – not least as I am well into the decade of older age – want to ensure we support its actions and its aspirations. It is up to each one of us to work with some speed to creating that Fairer Scotland which values age.   Dr Donald Macaskill CEO, Scottish Care