What is social care and how is it delivered?
The Health and Sport Committee heard from the Director of the Coalition of Care & Support Providers in Scotland, Annie Gunner Logan, as part of their Inquiry into social care during the pandemic.
If you would like to find out more about the Committee's work on social care, please visit https://www.parliament.scot/parliamentarybusiness/CurrentCommittees/113970.aspx
Transcript of the session from the Parliament's Official Report:
Hello, and thank you for the invitation to join the discussion this morning. I am very pleased to be here for this session. This is a pivotal time for social care, and I thank members for their continuing and enduring interest and attention.
I have not given you a fresh paper today, because the paper that we originally submitted back in February is still valid. I went back to it in June and wondered whether any of it would be relevant after Covid, and then I realised that not only is it still relevant, it is now hyper-relevant. I will pull out the key parts of that, with particular emphasis on the bits about commissioning and procurement—because they are of interest to the committee—and then I will talk about how things could be different.
First, I want to say something about what social care in the third sector is, what it does and why it matters; our paper goes into that a little bit. Social care in the third sector is not a service like other public services. We do not cure people, deliver their babies, put their fires out, bring them to justice or get them educated and qualified. We do not generally wear uniforms, and you will not see us in television drama series on Saturday nights.
What we do is get alongside people when they have very significant challenges in their lives and struggle to participate in society as full citizens, and we support them, wherever possible, to make their own decisions and move their life forward as best they can. Where the world makes it very difficult for people to do that because of their age, impairment or whatever, we do what we can to help by ensuring that they are comfortable, are cared for and can have at least some kind of independence and peace of mind in their individual circumstances.
When you look at what third sector care and support organisations say that they are all about, you do not find much about services; rather, you find things such as,
“Our vision is for the people we work with to live meaningful and independent lives in a world which supports them to achieve their own ambitions”;
“Our mission is to enable everyone to live a valued life—the life they choose”;
and “Your way to a brighter future”.
The shortest statement that I could find among our membership is simply: “We support good lives”.
It is hard to capture and summarise those organisations’ work, partly because what they do to support people in practice will vary according to individual need and preference. That work is not seen as particularly exciting, sexy or critical—certainly not to TV producers on a Saturday night. To have to live without it, however, leads to huge stress and distress for people and when that work becomes the focus of attention, as it has during the pandemic, everybody finds out how important it is.
Over time, a substantial architecture of legislation overlaid that basic proposition of a supportive relationship for people with challenges in their lives. The foundations in modern times were the Social Work (Scotland) Act 1968 and the Chronically Sick and Disabled Persons Act 1970—I am getting a bit anoraky already—both of which conferred very important rights on people with care and support needs as well as duties on public bodies to meet them.
The National Health Service and Community Care Act 1990 introduced the market to social care and, since 1999, the Scottish Parliament has introduced a significant range of additional legislation that refined, revised and modified all those acts.
Over time, we have also codified that basic proposition of a supportive relationship into a set of categories—home care, housing support, care at home, day services, respite and so on—and a set of tasks, generally to serve budgetary and monitoring requirements. Probably similarly to Eddie Fraser, I am long enough in the tooth to have been in front of a predecessor committee, during which we took a lot of time to identify what personal care might be and how it differs from any other kind of care—simply because we had put ourselves in the position of considering making some of it free but not all, so we had to codify what was free and what was not.
Over time, that codification has infiltrated our system to the extent that an awful lot of the supportive relationship that we have with people is now pre-specified as those categories and tasks—the latter often precisely timed, down to 15 minutes in some cases—in detailed contractual arrangements, again primarily for budgetary and monitoring purposes.
The risk is that those arrangements, rather than what people want and need, should now be described as social care. I echo some of what Eddie has said: we can help someone use the toilet, but we cannot run an errand for them; we can help them get dressed, but we cannot clean out the fridge—even if the errand, or the fridge, is what is really important to them.
That is what people mean when they say that social care has become service led, rather than person centred, which is what we all want it to be. I encourage the committee to see care and support not as a service but as a vehicle through which people who face all sorts of challenges can live their lives alongside those of us who are fortunate enough not to face those challenges. Eddie is absolutely right to say that it is a rights-based issue.
That thought is not original in any way and the independent living movement has put it far better than me. Committee members have probably already been referred to Inclusion Scotland’s “Our shared ambition for the future of social care support in Scotland”—I would highly recommend it if you have not.
The paper that we submitted back in February sets out what we think are the key ingredients for making a success of all that: the right policy framework, the right workforce, good critical challenge—we were clear in our paper that there is not enough of that—a diverse range of providers, appropriate use of digital technology, and so on. I am happy to go into any and all of that, but I will not repeat it all again today.
I want to say something about commissioning and procurement, because those are the mechanisms by which the third sector becomes engaged in all those issues. It is worth separating the two. Strategic commissioning is the exercise though which the needs of a population are identified, the desired outcomes for that population are agreed and decisions are made about what kind of care and support needs to be put in place to meet those needs. By its nature, that should be a very collaborative affair.
In contrast, procurement is not collaborative—it is competitive. It involves the codification of meeting assessed needs into detailed category and task-based specifications, which are appended to contracts and put out to tender using public procurement processes that are, fundamentally, no different from any other kind of public purchasing mechanism. That is why we find ourselves looking at documents in which groups of disabled people are described as “lots”, and why charities like our members have to bid against each other in order to be awarded a contract to support the people who are grouped into those lots. More often than not—and this is the critical part—such contracts are not underwritten by a financial arrangement that covers the cost of delivering them properly. When up to 80 per cent of a non-residential service is workforce costs, it is clear what will happen when we compete on price. If you ask me—the committee is asking me, which is why I am here—you can trace an enormous number of the critical failures in our social care system, particularly those that have been identified in the past six months, back to that issue. It is the root cause.
A good example that has already appeared on the committee’s radar is something that we discovered in the pandemic, which is that many care workers, especially in the private sector, receive only statutory sick pay if they have to self-isolate, which is why a fair few kept turning up to work when they should not have done. However, the national care home contract, which was drawn up by the Convention of Scottish Local Authorities and Scotland Excel on behalf of local authorities, does not allow for any more pay. Many care at home contracts that have been drawn up by individual councils do not allow for more sick pay either. It is not just about bad employers; although they undoubtedly exist; it is much more complex than that.
The position that is taken by central and local government procurement is that fair work is a matter for social care employers to sort out, so tendering processes need to be sharpened up even further in order to root out the bad employers—that is more or less what the guidance says. However, an awful lot of contract values are simply not sufficient to support much more than statutory minimums and plenty of providers get hauled in by commissioning officers and told to shave more off their price.
In any other kind of market, suppliers, which is what many of us have become, would take their business elsewhere, but in publicly funded social care, the public sector is the only purchaser in town. It is the opposite of a monopoly, where there is just one provider; it is a monopsony. Very few charities support self-funders. That is not the business that we are in, so we have only one purchaser.
For a hard-pressed public authority, the proposition of being able to control costs because its suppliers have nowhere else to go is initially very attractive. The public authority just lets the market do what it does: the providers compete with one another and bring the price down for the purchasing authority. Eventually, however, the public authority will run out of road, because a price-driven market in a monopsony under severe financial pressure will eventually see the quality providers exit the market. That is what we began to see pre-Covid.
So how could things be different? We have been working with our members on some alternatives to a competitive market in social care. We call them our big ideas. Fundamental to those ideas is the actualisation of self-directed support. We never liked competitive tendering much, to be honest, but the introduction of self-directed support is what tipped us over the edge, because we could not see how people could possibly be supported to exercise choice and control on their own behalf in a system in which all the choices about the support available to them had already been made for them by the procurement processes. Those two thoughts cannot be kept in one head at the same time.
Sustainability and the appropriate use of resources are also fundamental to our thinking, so we came up with four tests for any alternative to competitive tendering in the market environment. Does it shift power? Does it increase choice and control for individuals? Does it improve accountability and transparency? Does it improve social care sustainability? Having set those tests, off we went.
We are still working on our big ideas and at an appropriate moment—very soon, I hope—we will share them with the committee. For now, I can say that they include things such as alliancing, which is a particular type of contracting arrangement in which commissioners and providers collaborate with each other as equal partners in pursuit of a common endeavour, sharing risk and agreeing, rather than competing, on who does what and with what resource.
Those ideas include suggestions such as agreeing at a national level a suite of sustainable rates for different kinds of support, which everybody signs up to. Then, if we must have a competition locally, let us have it on quality, not price. When I refer to a sustainable rate, I mean a rate that will cover, and continue to cover, the cost of a properly rewarded and supported workforce, following fair work principles.
Those ideas also include a suggestion that we go back to grants, instead of contracts, again to stabilise our organisations and our workforce and, critically, to link the amount of grant, and its conditionality, to the meeting of individual need and outcomes, as required by self-directed support.
Therefore, our big ideas are just that: ideas. However, if I may respectfully say so, the national care service is just an idea. These are all half-formed things that have not yet been tried and which need a lot more fleshing out to see how they will work in practice. However, we know enough about what does not work to be able to give at least half a mind to what might work. That is the territory that we now need to enter. We are up for that. I hope that you are up for that. I will stop there and leave more time for discussion.