Scottish Government

Chapter 5: Links to other reports

As we have been meeting, other work has been underway which has resulted in a number of reports. The most significant of these have been:

• Building a Health Service Fit for the Future: the National Framework for Service Change (the Kerr Report) (May 2005).
• Better Outcomes for Older People: A Framework for Joint Services (May 2005).
• The future of unpaid care in Scotland: Report for the Care 21 Unit (September 2005 ).
• Report on Recent Trends in Capacity in the Care Home Sector in Scotland: Health Economics Research Unit, University of Aberdeen (November 2004)
• Changing Lives: Report of the 21st Century Social Work Review (February 2006).

We have seen the same issues being grappled with in various contexts by these reports. The challenges faced are the same, and are being recorded in similar terms in the different documents, whether it is health or community care, the future of social work or the place of carers, or north or south of the Border.

These reports are highly relevant to our task of models of care to meet the needs of Scotland's ageing population, and the following sections set out the most important features of these reports that we see as contributing to future services.

Building a Health Service Fit for The Future (The Kerr Report)

Building a Health Service Fit for the Future, also known as The Kerr Report (May 2005), sets a 20 year plan for the NHS and shifts the emphasis from hospital-based care to preventative, anticipatory care rather than reactive management.

It has a number of key messages, and these include:

• the NHS should be seen as a service delivered predominantly in local communities rather than in hospitals. It notes that 90% of health care is delivered in primary care, but the bulk of attention is focussed on the other 10% - the current emphasis on hospitals does not provide the care that people are likely to need
• preventative, anticipatory care rather than reactive management. The NHS should work with other public services and with patients and carers to provide continuous, anticipatory care to ensure that, as far as possible, health care crises are prevented from happening;
• galvanise the whole system; more fully integrate the NHS (including the contribution of hospitals, general practice teams, social care providers, patients and their carers) to meet the challenges;

The Report is wide in scope and contains a large number of proposals. The top 10 include:

• All NHS Boards to put in place a systematic approach to caring for the most vulnerable (especially older people) with long term conditions, with a view to managing their conditions at home or in the community and reducing the chance of hospitalisation.
• Targeted action in deprived areas to reach out with anticipatory care to prevent future ill-health and help reduce health inequality.
• Support for patients and their carers to manage their own health care needs and to help others with similar conditions.
• Set a clear agenda for Community Health Partnerships to work across barriers between primary and secondary care and engage with partners in social care to shift the balance of care.

We welcome these key messages and recommendations. The whole thrust of the Report is in line with our own thinking as to the way we see services developing in Scotland over the next 10 to 20 years.

Better Outcomes for Older People: Framework for Joint Services

Better Outcomes for Older People (May 2005) is a framework for joint services for older people. The Framework:

• promotes the development and mainstreaming of joint and integrated services,
• sets out the requirements which the local partnerships of NHS Boards and local authorities should meet in developing and delivering joint and integrated services.
• acts as a tool in developing joint and integrated services which assist older people to lead more independent lives and have more personal control over their lifestyles, care and environment. It provides advice and good practice examples.

In particular, the Framework signposts the way that joint and integrated services should be provided - in partnership between individuals and their carers, health, housing and social care organisations, in the statutory and independent (voluntary and private) sectors.

Part 1 describes types of joint services for older people, sets out the foundations for effective joint services -

• strong leadership
• a supportive organisational culture
• easy flows of information between organisations and professionals
• staff with the right skills and experience, and
• team working,

sets out principles underpinning joint service design, and deals with commissioning and evaluating joint services.

Part 2 has sections on -

• An Active and Healthy Life for Older People
• Promoting Independence at Home for Older People (covering care at home, equipment and adaptations, day opportunities, housing solutions, extra care housing, and Supporting People)
• Joint services for enhanced care
• Joint services for carers of older people, and
• Joint services for carers of older people with additional needs (learning disabilities, physical disabilities and sensory impairment, mental health, substance abuse, and dementia).

Better Outcomes for Older People is a valuable resource about the joint provision of services. Its use will help ensure older people get the services they need, regardless of which agency provides the service. It links into the Joint Performance Information and Assessment Framework ( JPIAF) and Local Improvement Targets. It supports the Group's view that by improving the quality and access to many services outside the NHS, including housing, transport, social care, physical activity etc, then older people will gain an improved quality of life and health problems will be mitigated or prevented.

The Future of Unpaid Care in Scotland

The Care 21 Unit within the Social Work Services Division of the Scottish Executive commissioned work on the future of unpaid care in Scotland over the years to 2014. Its report The future of unpaid care in Scotland was published on 30 September and is based on a number of core principles. These include:

• the need to recognise carers as key individual care providers
• recognition that families and unpaid carers constitute Scotland's largest care force
• the need to harness the contribution of unpaid carers for future care provision
• the need to make caring a more positive life-choice, and
• strengthening independent living and self-care, and improving quality of life and the quality of care.

Choice

Choice is a consistent theme emerging throughout the Care 21 work. Carers strongly request

• that they and the cared for person have more information and choice about the support available to them
• greater control over the solutions created to address their support needs.

The vision emerging from The future of unpaid care in Scotland is that by 2014:

• there will be a shift from crisis intervention to planned, preventative support
• unpaid carers will be better integrated in joint planning of care and service developments, and in local and national partnerships
• unpaid carers will be able to access a range of support provided by local community initiatives, and
• unpaid carers will enjoy good general health and well-being.

Demographic change means a growth in the number of older people with potential support needs, but also a growing number of retired people with energies and skills to contribute to community developments. Unlocking this potential within local communities to contribute to the development of flexible support services is highly desirable. Recommendations seek to harness better partnership working, volunteering, and capacity building for community support. The future of unpaid care in Scotland believes that supportive local communities can enhance 'self-care confidence' and that well supported community infrastructures and local care economies will enhance choice and local solutions.

The health needs of carers have already been recognised in Building a Health Service Fit for the Future (notably in chapter 5: Self-Care, carers, volunteering and the voluntary sector: towards a more collaborative approach), which makes 5 key recommendations. The future of unpaid care in Scotland makes recommendations that address these and other areas.

We fully support the direction set by this work for the years to 2014, which is entirely consistent with our own.

Report on Recent Trends in Capacity in the Care Home Sector in Scotland

One issue highlighted in the past was a view that the care home market has been largely left to the independent sector to develop, with the consequence that provision was patchy across the country. In some places it was thought to be very near its capacity, while in other places it was undeveloped.

The Executive therefore commissioned a study of recent trends in capacity in the care home sector in Scotland over the period March 2001 to March 2004 from the Health Economics Research Unit at the University of Aberdeen.

This found that

• The main factors that influence trends in the provision of care home places are: demographic changes; the health status of older people; the availability of alternative forms of care; socio-economic circumstances ( e.g. the number of older people living alone); and financial factors.
• Over the same period there has been an expansion in alternative forms of care for older people, especially the provision of home care services.

There are wide differences between local authorities in the relative use made of home care places for their residents. Nationally there are some 87 residents in care homes for every 1,000 people aged 75 and over, but the highest was 129 per 1,000 older people (Glasgow) and the lowest 55 (Edinburgh).

• The balance of care between the different services provided for older people varies between local authorities - some provide much higher levels of home care than others, and this may reduce their need for care home places.
• There is some evidence that the use made of care home places tends to be higher in areas with relatively high levels of deprivation.
• Visits were made to 5 local authorities: Aberdeen, Edinburgh, Glasgow, South Ayrshire, and Stirling. These councils generally felt that the decline in capacity was in line with the Scottish Executive's policy aim of shifting the balance of care for older people away from institutional settings, and some of them have invested substantially in recent years in the development of alternative forms of care such as home care services.
• The visits also suggested that new and innovative forms of care for older people are being developed, and that some of these forms of care may not be fully captured by existing statistics on community care services for older people.
• Factors that will add to the demand for care home places over the next few years are
  • demographic factors
  • the continuing decline in the number of beds for older people in NHS hospitals, and
  • the ongoing pressure to reduce the number of delayed discharges.
• Factors that will tend to reduce the demand for care home places include the continuing development of alternative non-institutional forms of care. Improvements in the health of older people may also reduce demand for care home places, though such improvements are likely to be slow and gradual and the impact of this factor over the next few years may be quite small when compared with the large increase projected in the number of people aged 85 and older.
• The target adopted for increasing the percentage of older people receiving intensive home care to 30% of all older people receiving long term care should also reinforce the trend away from institutional settings.
• The net effect of these different factors on the demand for care home places over the next few years is uncertain. It may be that the additional pressures associated with (a) a sharp rise in the number of people aged 85 and over, (b) continuing pressure to reduce delayed discharges, and (c) a further decline in NHS beds, can be met by expanding alternative non-institutional forms of care. This is likely to require substantial investment in these alternatives, and also effective management of admissions to care homes to ensure that these places are used only for those in the highest dependency categories.

Forth Valley Studies

We found that Forth Valley Health Board had done work that was of interest to us. There were 2 reports:

Community Hospital Bed Requirements (April 2004)

The purpose of this work was to estimate how many community inpatient beds would be required in Forth Valley following a proposed service and facility reconfiguration. The study looked at acute, community and care home bed requirements for:

• the current service model, allowing for population changes
• an alternative service model of early discharge from both acute and community hospitals (acute to community hospital, and community hospital to care home).

Capacity Planning Exercise Phase 2: Community Services (February 2005)

The principal aim of this study was to estimate the future requirements for community services. It found that if any of 3 growth rate assumptions fall true, then a large increase in the required levels of access to community health services will be required by 2013/14:

population and 1% access rate growth a year - 18% growth in community health services
population and 2.5% access rate growth a year - 37% growth in community health services
population and 5% access rate growth a year - 74% growth in community health services

It concluded by suggesting alternative ways of meeting these increases (without quantification), including Joint Future, Community Health Partnerships, ICT and new technologies.

These reports were the basis of early local developmental work in Forth Valley, and we felt they did not have implications for the rest of Scotland - each area has to do its own work to reflect local circumstances. But one fundamental lesson of the Reports is that even within closely defined parameters, and looking at a limited range of options, the outcomes vary widely ( e.g. the difference between 18% and 74% growth in services).

Independence, Well-Being and Choice

Independence, Well-being and Choice: Our Vision for the Future of Social Care for Adults in England was published as a consultation paper by the Department of Health in March 2005. It is set in the context of the UK Government's reform of public sector services.

Independence, Well-being and Choice is a vision statement with an emphasis on giving people more choice, higher quality support and greater control over their lives.

It addresses many of the issues that we face across the UK -

• higher expectations
• an ageing population
• the increasing numbers of people who live alone
• the problems of improving recruitment and retention of the workforce
• the issues of joint working
• capacity building in the community, specifically through working with the voluntary and community sector.

There is a good deal of commonality between the issues addressed in the Green Paper, in the other publications noted in this section, and those we address in the course of our work.

Changing Lives: Report of The 21st Century Social Work Review

The 21st Century Social Work Review was an independent review, commissioned in summer 2004 to take a fundamental look at all aspects of social work in order to strengthen its contribution to the delivery of integrated services. The report was published in February 2006 and draws 3 over-riding conclusions:

• doing more of the same won't work. Increasing demand, greater complexity and rising expectations mean that the current situation is not sustainable: Tomorrow's solutions will need to engage people as active participants, delivering accessible, responsive services of the highest quality and promoting wellbeing;
• social work services do not have all the answers. They need to work closely with other universal providers in all sectors to find new ways to design and deliver services across the public sector;
• Social workers' skills are highly valued and increasingly relevant to the changing needs of society. Yet we are far from making the best use of these skills: Tomorrow's solutions will need to make the best use of skills across the care workforce.