12 minutes to Midnight 5 months on
On 17th June 2018 Scottish Care published its short report, ‘Twelve Minutes to Midnight: 12 challenges, 12 solutions, 12 months to save the homecare sector.’
The report received, as might have been anticipated, significant media reaction though not all of it got beyond the headlines into the actions and suggestions that we were making.
We are now 5 months on and given today is Home Care Day, it might be appropriate to revisit progress.
So firstly what were the issues and suggestions?
1. The Scottish Living Wage
The last few months have seen the reality on the ground look even worse than it had been in May. It took several months after the commencement of the Scottish Government 2018 commitment for the monies which should have been allocated to finally reach the pockets of the providers. In some instances it was as late as September before several Scottish Local Authorities sorted themselves out and decided to pay external providers. This is unacceptable meaning either that frontline workers were not paid their increase because providers had no assets or reserves thus making retention very challenging. Or providers used the little additional reserves they had in order to pay workers until they received their payments. This again risk the sustainability of many organisations and meant in practice that resource that could have been used for innovation and development was lost.
It is a great pity that the flawed implementation of a well-intended measure has resulted in even less sustainability within the homecare sector.
We are very concerned of what the future might hold. One thing that Scottish Care is clear upon and that is that if this initiative is to continue it must be appropriately resourced, clearly ringfenced, properly implemented and externally reviewed. We simply cannot leave it to a wing and a prayer.
We must also seriously address the fact that the failure to pay differentials has now resulted in many organisations struggling to attract senior staff and managers.
With renewed pressures from Brexit and from the hospitality and retail sectors we must do more than a badly implemented and poorly resourced Scottish Living Wage initiative to secure the future of the valued homecare workforce.
2. Time and task commissioning
There is now no shortage of initiatives, including those of the Adult Support and Care Reform process from Scottish Government and work on a potential National Framework facilitated by Scotland Excel within the commissioning landscape. There are also emerging models in practice of collaborative models including alliance models. There does indeed seem to be a willingness to move away from the obscenities of time and task commissioning which has served to drive quality down and to develop outcomes based approaches. This cannot be done on the cheap and must be resourced to enable the step change which citizens require. Care in fragments, deserves to become a thing of the past. We must re-imagine the potential of as preventative, time-flexible, outcomes focussed approach to commissioning.
3. The model of care is not appropriate – not holistic not person led …
Scottish Care’s report, ‘Bringing Home Care’ was a call to develop prevention focussed, time flexible and relationship-based care. More than ever individuals accept the validity of these options but we are still struggling within a system that is failing to join up the dots. Despite the mantra of integrating health and social care and creating one system approaches, we still witness a fragmentation of resource and leadership. More than ever before we need to re-envision the sort of care we need to deliver. Investing upstream by re-shaping homecare will in the medium to long-term make significant fiscal savings and lessen an unhealthy dependence upon the acute NHS. But this requires courage and an active disinvestment from buildings and roles which are weighing down innovation. It is hard to prove a future which is calculated on not doing something without at least testing new approaches. We know what they are we need political will to start implementing them. Scottish Care is committed to continue to demonstrate the clear personal and societal benefits of a reformation of homecare and the development of housing with care models.
4. Recruitment of staff
As the Scottish Care Autumn Care Tour goes around the country there is one singular issue which is concerning providers of housing support and acre at home service s- that is recruitment and retention. All the evidence is that things are getting worse rather than improving. Providers tell us they are massively struggling to recruit staff. IN previous years people came through the door and were then sifted , now there are not even individuals who are showing an interest in social care. This isn’t too much of a surprise when we have a highly regulated sector, with qualification demand,. And low level remuneration. Go along the road and there are plenty of equally well paid jobs in retail and hospitality without the level of demand and external oversight, and societal stigma. We have a massive recruitment crisis. Inevitably this is already being made worse by the cloud of uncertainty which is Brexit. Providers are reporting that loss of staff is a reality now rather than an anticipation for next year. It is very difficult to encourage and recruit in such a negative atmosphere. We are pleased that there will be a Scottish Government funded campaign to attract workers and are happy to collaborate in its development. However, on its own, and without addressing the elephants in the room, it will be insufficient.
5. Holding on to existing staff
‘The Four R’s’ and the ‘Experience of the Experienced’ reports from Scottish Care’s Workforce Matters team have been published since the spring of this year. They paint a picture of real challenge around retaining the staff that we have in homecare. We know that 63% of staff leave within the first six months of joining an organisation. Retention is critical. We have to get better at holding on to the workforce we have because we know that for every 10 people who leave 3 never come back into social care. We have to explore with partners what are the reasons that people are leaving. We know that some leave because they and the work is not a fit; we also know some leave because of the stress and strain of the work and the way it is structured. But we also know that people say that they are not happy with the lack of autonomy, too much emphasis on regulation and compliance, and insufficient time to be with people.
6. Qualifications and especially older workforce fitness to practise…
Registration opened for frontline care staff a year ago and with it came a requirement to be appropriately qualified within a set timescale. Scottish Care shares the desire to have a well-trained, valued and recognised care workforce. But there are real fears out there, and these have been compounded over the last few months, that despite the supports, we will lose some of our most experienced and talented older staff because they will not want to go through the rigours of our current qualification system. Added to that Scottish Care believes that we need to radically reform the qualification system. We hear from providers that there are real problems in accessing local training providers, inflexibility in forms of assessment, an over-dependence on text and academic models amongst other concerns. We dare not lose the gifted resource of trained and skilled individuals who have worked in the sector for years but whose life-skills and prior learning is not being appropriately valued and acknowledged.
7. Emotional fatigue… mental health stress and distress
After terms and conditions, we know from our research at Scottish Care that the second main reason that people choose to leave social care is because it is such an emotionally draining and demanding area of work. ‘Fragile Foundations’ was published nearly a year ago and describes the often draining and exhausting reality of care and its impact on the mental health and well-being of the workforce. There have, over the last few months, been a considerable degree of political focus on mental health and wellbeing, not least of children and young people. We need the same level of commitment to older person’s mental health in general and a particular emphasis on the mental fatigue being faced by the care workforce. As we have said we must all get better at caring for the carers.
The establishment of a Review of Health and social Care Integration is to be much welcomed. Scottish Care is grateful to be included in that review which is an important acknowledgement of the fundamentally important role that the independent care sector plays in delivering services across Scotland. We all want the aims and vision of integration to work in reality. The next few months will involve the need for courageous thinking and creative work to ensure that the benefits of a one system approach are truly achieved. We look forward to building upon this early work both at national and local level. In the midst of this we continue to encourage local Integrated Joint Boards to give formal recognition to our contribution by having a representative from the sector on the Boards. Since we last reported the Scottish Care Partners for Integration staff have produced a report and held a conference which highlights the work of the independent sector across integration authorities. It is clear from that when we work together we achieve the joined up and positive outcomes which our citizens desire.
9. Technology used to limit rather than to liberate
There is tremendous potential in technology to transform and deliver a more person-led, preventative approach to home care and housing support. Scottish Care has long argued that this technological contribution has to be undertaken for the right motives – to enhance person-led care and support, and in the right way – embodying human rights at the heart of care. To that end we published a report called ‘TechRights’ in August. It is a call for a human rights based approach in the developing use of AI, Big Data and the Internet of Things within social care. It is our hoped that the partial engagement of the independent sector by other stakeholders will increase over the next few months. The future of care necessitates all of us working together.
As part of that future for homecare we have been delighted to have been working with the Glasgow School of Art School of Innovation in a project which has technology at the heart of a vision of homecare for the future. We hope, after our Autumn Care Roadshow, to write up our findings and specific recommendations.
10. SDS needs to work better for older people
Self-directed support (SDS) is the only way that citizens should be accessing social care – but for many older Scots the principles of choice, control, participation and dignity are still being daily ignored or only partially offered. We are still hearing stories from across Scotland, often on the grounds of fiscal austerity, that older people are not getting the same access to choice. This is not the fault of SDS , this is the fault of a social care system not enacting the legislation properly and a lack of resource to implement the change we all want to see.
Scottish Care is absolutely committed to ensuring our citizens are able to exercise choice and control, have a clearly identified personal budget and that there is a diversity of the market to enable real choice to happen. We will resist any attempts, including political ones, to water down or neutralise this potentially life-changing legislation and delivery model. We will continue to be strong advocates of self-directed support and its potential to put the citizen in control of their own care.
11. Social care is underfunded
We are a few weeks away from the Scottish Budget Statement and over the next few weeks Scottish Care will be publishing our own Budget for A Caring Scotland. Every year we are faced with the uncertainty of lack of finance in the social care system in Scotland. Every year at budget time we at Scottish Care make a call for substantial funding to bridge the care gap which is getting wider and wider as our population ages, as dependencies increase and as services cost more and more.
We remain deeply concerned that there is a lack of political energy beyond political party interest and ambition to gather around the table and properly explore how we will fund social care in the short and medium term. As others elsewhere, for instance in Wales, are holding robust conversations with citizens on funding care we hear a deafening silence in Scotland. We need to start having a debate which will be central to the social fabric of our communities and to the maintenance of effective care at home and housing support.
- Discriminated and devalued
Our last statement was that we believed that one of the most significant issues facing the social care of older people is the pervasive discrimination which many older Scots and those organisations who support them continually experience and talk about. We have not seen this alter over the last five months, indeed if anything, because of a simplistic analysis of Brexit voting we have seen it increased. Such stigma and stereotyping needs to be called out for what it is – discrimination based on age. The creation of an inclusive Scotland cannot be created on a foundation which is inherently ageist.
Starters at midway point
Our previous report listed 12 specific starters – let us see how we are progressing…
1.Emphasis on prevention
We called for investment in tests of change, in developing new models rooted in prevention and self-management for the old and frail, which is non-condition specific but designed to enable independence and is person-led. We asked any Integrated Joint Board willing to work with us to get in touch. We are still waiting.
We called for a change in commissioning to make it collaborative and relational. We are thankfully beginning to see a growing collective and governmental desire to make this happen.
3. Learning needs to grow up
We called on partners to work with us to radically alter the way we validate and recognise care worker learning and experience. We invited the SQA and SSSC to work with us so that together we can create a qualifications framework which is built around the needs of the person rather than the system. We have started the process of discussions and debate but we believe there is still a resistance to making the radical change we need to see.
4. Utilise technology by equipping workforce
We called for the creation of a five-year Technology for Social Care Project Fund – to fund creative technology designers to work with frontline care workers for a month and then out of that experience to design innovative solutions for practical problems in collaborative partnership. We still believe this is a good idea – we are still waiting on our colleagues in the Scottish Government’s Digital Health and Care Team to get in touch.
5. Let us all try and make the Scottish Living Wage initiative work
Scottish Care is committed to the maintenance of this initiative from the Scottish Government. We have to get better at its implementation and adequate resourcing. We are continuing to work with our partners in seeking to achieve this positive outcome. The next Budget has to clearly delineate priority for social care staff. We would encourage our politicians to note that the Welsh Government has made social care its fourth area of economic priority.
We called for the creation of a Pay Commission to be established to decide what is an adequate rate of pay for those engaged in the increasingly skilled and challenging tasks of care in our community. We are still waiting for buy in.
6. Prioritise learning and development
In order to recognise the critical role of training and learning in homecare , and in response to the growing reduction in funding through contracts for staff training, we called on commissioners to ensure that at least 10% of the whole sum of a tender should be committed to the training, learning and development of the workforce. We have not seen anyone do this.
7. Respecting the workforce
In recognising that it is time to trust our workers by giving them power to make decisions, to act autonomously, to feel that they are trusted and valued, professional and capable, we called upon SSSC and others to work with us to change the workforce regulatory culture from one of compliance to partnership, one of fitness to practise to freedom to perform. Discussions continue but we believe we have not got the balance right and that regulation is still disproportionately heavy.
8. Care for the Carer Fund
Faced with all the evidence we have published on worker stress and distress, on burnout and fatigue and the critical importance of retaining the workforce, we called on the Scottish Government to establish a Care for the Carer Fund dedicated to ensuring the mental health and well-being of frontline social care staff. They are our greatest asset to hold on to and our easiest treasure to lose. We have not seen this come to fruition.
9. Distinct bereavement support for every worker
In accepting that most social care for older people is at the interface of palliative and end of life care, that the social care workforce offers solace in distressing times, we argued the need to support that workforce better. In so doi9ng we asked Scottish Government to prioritise bereavement support for the workforce through a joint national project with Cruse Bereavement Scotland to establish a network of bereavement support for care professionals. We have not seen this suggestion taken up.
We argued that in order to make integration work it should be a requirement to include representatives of the independent sector social care providers and frontline workforce on IJBs to have their voices heard. We still believe that you cannot have partnership without presence and yet still most IJBs do not have a sector representative.
In recognising the substantial contribution of social care to the wider Scottish economy we called for the creation of a special division or unit within Scottish Enterprise dedicated to enabling the greater promotion and development of social care and to fostering and co-ordinating innovation and entrepreneurship for the benefit of the wider economy. None such has been developed.
Alongside this we are called for Skills Development Scotland to strategically work with organisations like Scottish Care to focus more of its priorities and resource on the social care sector. We have had constructive dialogue and progress in parts of this over the last five months.
Our last suggestion was that we create a cross-party and independent Commission on the Future Funding of Social Care in Scotland. We acknowledge the reform work that is ongoing but our call for an urgent exploration of the financing of social care and health in Scotland has gone unheard
Scottish Care as the representative body for the majority of older people homecare organisations is disappointed that five months after we identified 12 critical areas to be addressed and offered 12 solutions to meet the challenges facing social care that the vast majority have not been accepted or acted upon.
On our calculation we are seven months closer to a point of real breakdown. Every day across Scotland we are faced with a homecare sector struggling for survival and sustainability.
The thousands of women and men who work in the services , and the thousands who receive support, deserve better than a countdown to even more chaos and disintegration in the care and support they received. We need to all of us work together to make the change that is needed, and to nurture the care that changes us all from bystanders to active citizens in creating an inclusive Scotland.
We hope next May to say something very different.