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    Joint authors:  Colin Slasberg and Peter Beresford

    We have previously set out why we believe the Feeley review of Adult Social Care in Scotland has the potential to be truly ground breaking. Its first and primary recommendation is that social care should be established on a human rights basis. Whilst it also makes recommendations about structural change, the report recognises that structural change without cultural change is no change at all.

    While the rhetoric of human rights has littered social care policy for at least two decades, Feeley is not the first to recognise it simply hasn’t happened. Whilst there are examples of excellence, they are not the norm. However, what makes the Feeley report different is that it goes further. It pinpoints the practical changes required. These focus on the process of assessment, support planning and resource allocation. Three recommendations are of particular importance;

    1. ‘People should understand better what their rights are to social care and support and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    2. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    3. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

    Delivery of these three recommendations alone would have far reaching consequences. They would amount to the abolition of eligibility criteria to identify ‘need’ and control spending. This would lead to the re-purposing of the entire system from its current protection of public resources to one that serves to promote the human rights of older and disabled people, whatever level of funding the democratic system happens to make available to it.

    The early responses

    The Feeley report was warmly welcomed by all parties in a debate in Holyrood on February 16. The Scottish Government committed to working toward a way forward ahead of the May elections.

    However, there remains deep scepticism amongst activists and academics. For some it is born of many years of national and local government talking the talk of rights whilst walking a very different walk. For others there is disappointment Feeley did not demand funding to meet all need as the precondition of a system based on human rights, or to the structural changes they favour, or to renationalisation of social care as the solution its ills.

    The following sets out nine key tests by which to judge the authenticity of the Government’s intentions in how they respond to Feeley. They set out the practical steps required if Scotland is to deliver the Feeley recommendations.

    Nine key tests

    1. Government will establish the principle that in social care, as in the NHS, need will precede resources. A founding principle of the NHS was that clinicians must be free to identify clinical need and the resource consequences must follow. People generally trust that NHS clinicians will indeed identify to the best of their knowledge what modern medicine can do to give them the best possible health. This is not the case in social care where decisions about ‘eligibility’ are made ‘above people’s heads’. If Government declares that social care will join health care in putting need before resource, social workers will be free in line with their professional ethic to identify what will give people the best quality of life their circumstances allow. This, in itself, is arguably the single most transformative change that will deliver for social care the ‘1948 moment’ Nicola Sturgeon says she is seeking. The following eight all rise from and are a consequence of this one change.
    1. Government will declare the end of the eligibility system. The eligibility system, whereby ‘need’ is defined against so-called ‘national’ criteria, ostensibly exists to deliver equity. The scale of the inequity in levels of provision between councils identified by the Feeley report is testament to its failure. What ‘critical and substantial’ means varies from council to council according to their resources. The durability of the eligibility system is owed therefore, not to the pursuit of equity, but to control of spending. Success in controlling spending in this way comes at the expense of the resource-led and controlling practices the Feeley report so roundly condemns.
    2. Government will declare a commitment to fund all needs for people to have a dignified quality of life to the best of its ability. The Feeley report does not recommend Government commits to funding all needs. No public service is guaranteed the funds to meet all its responsibilities, not even the NHS. However, the necessary process of prioritisation should not and need not lead to loss of vision and moral purpose. Government should lead the way in ensuring the needs of older and disabled people compete on a level playing field with all other public services, currently denied by the eligibility system.
    3. Government will require systems are established that aggregate and report unmet need. Unmet need is the inevitable consequence of adopting the principle of need preceding resources. The NHS equivalent is waiting times. At the operational level waiting times provide the safety valve when need exceeds resources. At the strategic level, they tell political leaders the level of funding they need to make available. In social care the eligibility system denies them such information. Unmet need must be seen as the social care equivalent of waiting times in the NHS. Information about unmet need must be in the public domain, easily accessible and able to hold political leaders to account.

    Councils have sometimes in the past experimented with boxes on assessment forms for social workers to record unmet need. The information languishes in filing systems, goes nowhere and quickly falls into disuse. Government must avoid repeating such a mistake.

    1. Government must acknowledge that regional equity depends on the level of resources available to local authorities and is a national responsibility. Whatever else a National Care Service may comprise, national government must accept responsibility both to ensure that resource levels minimise unmet need, and are fairly allocated regionally.
    2. Government must require councils to establish systems that control spending without compromising assessments. No matter how large or small the gap between needs and resources, it is a fact of life than spending will have to be contained within budgets. Case by case decisions to determine eligibility as the means to do so must be replaced with case by case decisions that determine This will require a complete re-engineering of the decision making infrastructure, including financial and IT supports. Whilst equitable allocation of resources at individual budget holder level will continue to be important, it will be joined by value for money as no less important a challenge. A budget holder’s task will be to achieve the greatest quality of life for the greatest number of people within their budgets. This will require significant re-skilling of budget holders
    3. Government must require councils to democratise their assessment process. Assessing for eligibility spawns a bureaucratic, obscure and professional-centric process. Such processes must be swept away. New processes will be required that are accessible to all service users to support them to think through and declare their own assessment of their needs and support requirements. The council only has to be concerned that such self-assessments make the best use of resources so the person can have the best quality of life their circumstances allows. The social work role will be to support people to achieve such a self-assessment, working to whatever depth is required. An open, democratised assessment process is key realising the Feeley recommendation that assessments must be ‘co-produced’ and for people to have authentic choice and control over their support.
    4. With the system fundamentally re-purposed, Government will need to ensure there is a workforce development strategy. The social work role will be transformed from the current ‘piggy in the middle’ role to being able to work in authentic partnership with service users. It should come naturally to those whose value base is person-centred and also to social workers who are professionally qualified.

    Re-skilling will also be needed at the most senior levels too. Directors of Social Work will no longer have the task of managing a system that makes ‘need’ fit within whatever resource their political masters give them. Their task will be firstly to get the best from the given resource, and then to inform their political leaders of the shortfall. Their relationships will change. They can truly become the champions of the community.

    1. A transition strategy for existing service users. Resource-led assessments for ‘eligibility’ and person centred assessments are as chalk and cheese. Whilst the former is a negative exchange to see how bad life can be, the latter is a positive one to see how good life can be. However, there will be overlap. Some needs previously deemed ‘eligible’ will continue to be needs within a human rights based approach. There is a clear moral argument that existing service users should not be penalised by the change. All needs previously considered ‘eligible’ that also meet needs within the reformed system should be subject to a guarantee of being met as long as the need remains.


    For the above reasons, Feeley puts Scotland on the brink of becoming a world leading country in the delivery of social care. It would be one built upon the lived experience of each and every older and disabled person in need of state support. However, in the absence of pressure on Government to deliver the radicalism of the above agenda, the greater fear is that it won’t happen. Feeley’s plea for a system driven by human rights runs the real risk of being reduced to a pre-amble to the Government’s response that will amount to yet another reiteration of warm words and good intentions.

    Implications for England

    Whether or not Scotland does move forward, the lessons England could pick up are clear. England, whilst using different words, operates the same eligibility system as Scotland. England, too, has regional inequity of enormous proportions. Most service user groups will recognise the Feeley report’s description of the assessment and support planning process. It is bureaucratic, damaging and alienating.

    Debates in England are dominated by the funding issue. That takes the form either of focusing on the balance of public and private funding, sources of taxation or funding levels. There is, however, little debate about the vision for social care. Isolated Members of Parliament sometime raise the issue of a vision for social care, but those debates are not entering the mainstream. Yet without vision, how can the service know it is getting the best it can from the resources it has? And without vision, how can the public know what they are being asked to support, and how can political leaders know what they are being asked to fund?

    The issues Feeley is inviting Scotland to grapple with are issues England should grapple with too.



    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

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    This is SHA Scotland Secretary Dave Watson’s contribution to a Jimmy Reid Foundation paper; ‘Reconstructing Scotland after COVID-19: learning further lessons from the pandemic.’

    A Scottish Care Service

    Even before the pandemic, it was clear that the social care system in Scotland was in urgent need of reform. The current system is underfunded, lacks capacity, and has major workforce recruitment and retention problems with fragmented delivery through a discredited commissioning process. When former Conservative ministers are openly talking about the nationalisation of care homes, there is widespread recognition that there is a problem (even if not agreement on what should be done to solve the issue). The system is not just failing those who need social care but is also damaging the NHS with over half a million hospital bed days lost every year because of delayed discharges at the cost of £120m. These problems have been magnified during the pandemic. The lack of Personal Protective Equipment (PPE), inadequate testing, minimal sick pay, and use of agency staff, have all contributed to the tragic deaths in care homes and amongst social care staff. Care at home has also been impacted with care packages reduced or abandoned. Informal carers have all too often been left to pick up the pieces.

    The concept of a (national) Scottish Care Service (SCS) as part of the solution is not a new one. It has been Scottish Labour policy for a number of years, most recently as a 2019 General Election manifesto commitment (see p35 here). My own organisation, the Social Health Association, outlined the idea in its recent social care consultation paper. And, UNISON Scotland has recently published what it describes as a ‘road map’ towards the creation of a national care service. But while there is growing support for the principle of a Scottish Care Service, many in the sector have reasonably asked what it means in practice.

    There seems to be a consensus in favour of a national framework rather than a service delivery organisation or making it part of NHS Scotland, not least to recognise the different models of care. But that leaves open what the SCS would undertake directly and what would be the governance arrangements. A national framework approach must end the current marketisation of social care. It could set consistent standards, contracts and charges for services not covered by free personal care. Most importantly, it would include a statutory workforce forum to set minimum terms and conditions, organise effective workforce planning and put a new focus on training and professionalism.

    On governance, the usual approach would be to create a new Non-Departmental Public Body (NDPB). This would leave the SCS with a similar democratic deficit to NHS Scotland and would undoubtedly be populated with the ‘usual suspects’ by the ministers who make the appointments. As the service will be delivered locally, another approach would be to create a joint board from councils across Scotland. This was a solution UNISON Scotland proposed for police and fire, which had the added advantage of keeping the VAT exemptions. The joint board could have places for relevant stakeholders, including users and worker providers.

    A national service would also need to address regulation. The Care Inspectorate’s ‘light touch’ response to rising complaints has highlighted the need for reform. In fairness, it has been constrained by the Scottish Government’s own ‘Better Regulation’ code, together with inadequate powers and resources. There would also need to be a review of workforce regulation currently administered by the Scottish Social Services Council and UK professional regulatory bodies.

    If the service is going to be delivered locally, this leaves open the question of local governance and ownership. As the Accounts Commission noted in its annual overview, the current system of Integrated Joint Boards (IJBs) has struggled to deliver integration or a shift in spending from hospitals to community care. There have been many attempts to improve integration in Scotland since the joint finance arrangements of the 1970s and all have struggled. It may be that this iteration will eventually deliver, but many will argue that it requires stronger democratic accountability to make difficult decisions, and that means a bigger role for councils. This happens in other parts of Europe, but even here, they have not always shifted resources from hospitals to community services.

    Greater integration does not require staffing integration. Professional barriers have been broken down in recent years, and joint teams have shown that they can work effectively together, particularly when physically working together in community hubs. A huge staffing reorganisation would create stasis, just at the time when we need to free up staff to innovate. When IJBs were created, I – as a UNISON Scotland official – wrote a workforce framework, which would have addressed many of the current problems. Sadly, workforce issues were largely ignored at the time.

    The fragmentation in service delivery is a significant problem that does need to be addressed with more than one thousand care at home providers, and the scandal of care home firms registered in tax havens. In the short-term, the pandemic has highlighted the need for greater coordination on issues like procurement. Abolishing the market, standard contracts and common workforce standards will help shift resources to the front-line. In the medium-term, there should be greater common ownership, particularly in residential care.

    Common ownership does not preclude innovative voluntary sector operators who can meet the new standards as the best in the sector already do. The private sector likes to make a false link between personalised care and marketisation. All care should be personalised, and that requires a range of services, not a range of ownership models. Local delivery should also be about greater innovation in service delivery, trying new models of care that integrate people with care needs into communities.

    Finally, there is the tricky issue of funding. In England, the issue has at least been considered in the Dilnott Report, although it was overly focused on protecting assets. In Scotland, we cannot simply hope for the Barnett consequentials of reform in England to plug the current funding gap, let alone future demographic pressures. It requires a mature conversation with citizens about taxation. If we want to go further and fund care on the same basis as the NHS, then the conversation shifts to proposals like the former health minister Andy Burnham’s care levy, which involved a form of inheritance tax. Calling it and similar plans a ‘death tax’ is not a mature conversation.

    The creation of a Scottish Care Service is an idea which has come of age. Turning it from a concept into a practical solution requires more work and some difficult conversations. If we are to ‘Build Back Better’, as the Tories implore, an integrated health and care service, with national standards and local delivery should be the highest priority.

    Dave Watson, Secretary of the Socialist Health Association Scotland



    At this stage a debate about the post-Brexit UK Internal / Single Market is unlikely to generate much heat or light – expect for possibly amongst a select band of constitutional lawyers and academics and the most committed of political anoraks. And yet the UK government’s July white paper on the subject has the potential to radically re-fashion how public services are delivered across the UK and to finally precipitate the disintegration of the United Kingdom. The implications of the Northern Ireland Backstop will be small beer compared to the possible fallout from these UK Internal / Single Market proposals.

    Already the UK devolved administrations have expressed their alarm and concern at what the white paper proposes and have demanded a total review of the UK Government’s approach. They see it as a naked power grab by Westminster which will put the UK’s devolution settlement into a rapid reverse gear.

    Until the end of the present Brexit Transitional Period the EU Single Market rules will still prevail. They guarantee the free movement of goods, capital, services, and labour, known collectively as the “four freedoms” and a level regulatory playing field in areas such as  agriculture, fisheries, food standards and environmental policy. This is policed by the EU Commission and the EU Court of Justice. While this external regulation was an unacceptable pill to swallow for hardline Brexiteers, in the main it was judged as fairly objective, detached and objective legal process. But with the end of the Transition Period this framework will disappear.

    The four UK Governments up to now have agreed the need to for a collaborative approach to provide UK citizens and business with high and consistent standards in key areas such as the employment law, movement of good and people, environment and animal welfare. And there seemed to an acceptance to respect the devolution arrangements that have evolved within the UK over the last two decades along with a shared view on the need to develop “Common Frameworks” and dispute resolution procedures which provided for a parity of esteem and safeguards for all parties.

    But the white paper on The UK Internal / Single Market is a very much a “made in Westminster” document reflecting the ideological and policy preferences of the present Tory Government. And this lack of common and shared ground with the devolved administrations  has generated the hostile reception that it has received.

    At its heart the white paper proposals is a Westminster legislative route with the use of the courts as a means of dispute resolution. The lack of a clear process for the participation devolved administrations creates the risk that many areas of devolved policy could find themselves subject to the demands of the UK Internal Market. There is a lack of clarity about which matters should be left to market competition and which matters might be subject to regulation on social, public health or environmental grounds. These are essentially as much political issues as they are technical implementation processes. But where will the judgements lie?

    The risks are even greater as the UK Government itself will remain the final arbiter in international trade and treaties. As these treaties will be binding on all of the UK, the lack of a means to involve the devolved administrations could means – “Westminster rules, like it or lump it”. The track record of the Westminster Government of involving the devolved administrations in the Brexit process or even the response to Covid-19 does not bode well for any set of arrangements that are not copper-fastened by firm commitments to respect the devolution settlement in the UK and which work with the devolved administrations as equal partners.

    Seeking to address these concerns will overlap with the UK’s final departure from the EU regulation at the end of this year and will in turn run into next spring’s elections for the Scottish Parliament and Welsh Senedd. There they are bound to take on additional significance as voters will also be having an opportunity to also cast a judgement on the performance of Boris Johnson’s Tory administration to date.



    SHA Scotland Meeting

    Further to the notice of the AGM to be held on 23 January, I am writing to notify members of an additional agenda item.

    ·         Scottish Labour Deputy Leader nomination – There are two validly nominated candidates after the first stage – Jackie Baillie and Matt Kerr. The next stage is CLP/Affiliate nominations and SHA Scotland is entitled to make one nomination.

    The UK Party Leader and Deputy Leader nominations are the responsibility of UK SHA and all paid up members should have received a communication from them on this issue.

    I look forward to seeing you on Thursday.

    Yours fraternally

    Dave Watson

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    I have been requested to post the Scottish Labour Party Manifesto 2019.


    Comments Off on Scottish Labour Party Manifesto 2019

    Councils can make a huge contribution to tackling health inequalities across Scotland. The interaction and relationship with the Scottish Government is pivotal to making a difference.

    National recommendations for action:

    Funding: Reform the resource allocation to local authorities to ensure that it is based on socioeconomic circumstances of communities.

    Income: Reform Council Tax and create fairer local taxation.

    Structures: Further work to reform local authority structures -balance between local and regional services and integration with wider public services, particularly the NHS and public health services.

    Local recommendations for action:

    1. Priorities: This is about priorities and decisions. Tackling health inequalities should be the top priority for councils. All other roles and actions of local government contribute to narrowing inequalities in health, wellbeing, and life expectancy inequalities in their populations.

    2. Education and Schools: Ensures schools develop social, emotional, health and wellbeing agendas as a foundation for learning. Schools can do more to promote physical activity and improve the nutritional value of school meals. Free school meals and the provision of breakfast has long been an important public health measure. Resolve the crisis in Additional Support Needs education.

    3. Physical Environment. How the environment can be improved including reducing air pollution, a major cause of death in Scotland. Councils and health boards also have a statutory duty to reduce carbon emissions as part of their climate change plans.

    4. Food policy. Further action to improve healthy food in schools and other local authority settings. Wider action to improve access, affordability of healthy food. In addition to the key environmental health role in better food safety.

    5. Active and Affordable Transport. An active transport plan not only reduces carbon emissions but also contributes to better health. Traffic management measures can reduce accidents that disproportionately impact on poorer areas.

    6. Early years provision: This requires universal provision delivered by qualified staff, not just child minding, and can be an important setting to deliver health improvement such as toothbrushing, hand hygiene, dietary habits, and also venue to engage parents and carers.

    7. Housing: Council should be building and refurbishing more social housing and supporting a fuel poverty strategy through energy efficiency standards and measures. A warm, dry house is an essential element on any health strategy.

    8. Licensing: Using planning and licensing powers to address number and distribution of alcohol, gambling, and unhealthy fast food outlets.

    9. Economic powers: Using economic powers support regeneration of disadvantaged communities and help people to find and stay in good quality jobs. Procurement powers should promote fair work practices, including the Scottish Living Wage.

    10. Voluntary groups: Supporting community groups that help develop strong resilient communities.

    11. Community development and participation: Invest in community development and build better systems to ensure genuine community participation in local policy development.

    12. Leisure and culture facilities: Maintaining and developing cultural and leisure facilities that promote good health, ensuring access for all. Improve affordability and access.

    13. Exemplar Employers: As employers, develop fair work practices with well designed and paid jobs. Promote healthy workplaces with first class occupational health services.

    14. Care services. Social care services should be developed focusing on improving care workers pay, training, working conditions, as well as improving standards and regulations. This also means supporting collective services like day care, which tackle social isolation, particularly for older population.

    Life expectancy in Scotland

    No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government.

    Through their planning powers, management of transport and traffic systems, open public spaces, and leisure and cultural services, they can contribute to the quality of the built and social environment. They have powers to promote equality and wellbeing. They work in partnership with the NHS and other agencies such as the police, and voluntary & community organisations to support public health by leading community planning. In short, they make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age.

    Rising demand on the NHS and a growing funding gap means that our current health and care system is creaking at the seams. Addressing this requires a shift from the treatment of ill-health to preventing it. Above all health inequalities remain Scotland’s most urgent health issue.

    As our National Commission on Health Inequalitiesi highlighted, too often solutions are focused solely around the NHS. In practice many of the policy levers rest with local government and they are well placed to influence the wider determinants of health. Not least because of there close connection to communities and their role in coordinating how best to use all the available assets to promote well-being.

    In this paper we make the case for health and well being to be central to the purpose of our councils – recognising that they have to be fairly funded to make meaningful interventions.

    How councils contribute to a healthier Scotland

    Services like refuse collection, street cleaning, dealing with fly-tipping, and environmental health directly ensure that we avoid ill health by removing the sources of disease from our communities. Living in pleasant surroundings rather than litter-strewn streets and accessing cultural facilities are also good for mental health. Sports centres, parks, and allotments offer free or inexpensive routes for people to keep fit, active and healthy no matter their age or ability. These are essential health services.

    Local government also delivers direct health and care services: free personal care for the elderly, care homes support and adaption’s for people living with disabilities and chronic health conditions. These services save lives and are essential to the quality of life of many Scots. Without those lots of people would still be in hospitals, unhappy and costing a great deal more money. Housing is also a key health service. A decent safe secure affordable home is vital to both mental and physical health.

    Education and the tackling the educational attainment gap is essential to addressing health inequalities. As well as teaching the subjects children need to pass exams and get jobs, schools deliver a range of health and relationships education. Schools are important settings for implementing healthy food and physical activity policies. Schools are also the gateway to a range of other agencies that can support families like educational psychologists and social workers. Ensuring that children have the best possible start and make good choices about their own lives and health will not only mean they have better lives but that we can look forward to long term savings. What the Christie Commissionii called preventative spending. The Childsmile – national supervised toothbrusing programme in nurseries is a case study in preventative spendiii. There is also a crisis in the inclusion and support for Additional Support Needs children in Scottish schools with a postcode lottery in how this is delivered.

    The role of the councillor is recognised by NHS Health Scotland in their elected member guidanceiv. They describe the role of the councillor “as very important in terms of influencing the positive health of communities and ensuring the gap between our more affluent communities and individuals and those not so well off, isn’t widened.. Councillors are the key advocates for their communities and for ensuring tackling health inequalities is central to the purpose and work of the local authority.

    Some councillors also have a direct responsibility for the delivery of health services. Every council is represented on their health board, providing the only local democratic accountability health boards have since the decision to abandon direct elections. Others serve on Integrated Joint Boards tasked with coordinating the provision of community health services and social care. Councils also lead community-planning partnerships.

    Councils also invest in community development to build local capacity to respond to local needs. Single Outcome Agreements should include clear outcome measures for reducing inequality and health inequalities, together with the commensurate resources targeted on greatest need. This should lead to the development of greater resilience enabling individuals and communities to withstand challenges such as poverty, inequality, worklessness and other factors that endanger health and wellbeing.

    Lessons from elsewhere

    The transfer of public health from the NHS to local government and Public Health England (PHE) has been viewed in England as a significant extension of local government powers. Public Health England has published a range of resourcesi that promote good practice. Their focus is on good quality jobs, reducing social isolation and improving health literacy. While Scottish local government doesn’t have the same explicit powers, it shows the advantages of better links between public health practitioners and local authority teams. A number of local guidesii emphasise the role of councillors in health.

    In London, there is a collective agreementiii with national partners to transform health and wellbeing outcomes, inequalities and services, through new ways of working together and with the public. The Marmot Review also includes examplesiv of how local action can tackle health inequalities.

    Across Europe, local government and health work together more closely. In some cases unitary authoritie join up community health and other services. Norway, a country of similar size to Scotland does this. Although they would say that the division between acute and community services is just as challenging.

    While the centralising tendencies of the Scottish Government means similar structural change is unlikely in Scotland, we can learn the lessons from elsewhere, use relevant resources and adopt best practice that can support local action. The Scottish government has set a direction for public health in Scotland.

    Council Health Strategy

    The starting point should be a political strategy for the council to engage with a health equality agenda. This strategy shows how the council can make positive interventions, sometimes described as ‘place-shaping’. Sir Michael Lyons in his influential report, ‘Place-shaping: a shared ambition for the future of local government’, described ‘place shaping’ as the creative use of powers and influence to promote the general well-being of a community and its citizens. He said that local authorities must use their ability to bring together local stakeholders and develop a vision for their area.

    This should be developed in conjunction with community, voluntary groups and trade unions. Councils are the democratically elected representatives of their communities and should use that role positively to improve engagement in health issues. All policies should be measured against their contribution towards reducing health inequalities and resource allocation should be focused on disadvantaged areas.

    The strategy should include a health profile that gives councils information about the health of there own residents. This should include data available about health inequalities between different groups, such as men and women, older and younger people, people from different ethnic groups, which enables councils to make interventions targeted at improving the health of groups most in need.

    Councils are represented on health boards and Integrated Joint Boards, but rarely take a strategic approach to their role on these bodies. They should take their health agenda forward using these roles.

    In a practical sense, councils can help health boards by refinancing health PPP schemes as set out in UNISON Scotland’s Combating Austerity toolkit. The money saved should be invested in tackling health inequalities that address the council’s health strategy.

    Co-locating health and local government services is a good way of delivering seamless services, designed by staff and service users from the bottom up. Community hubs as described in the Health Inequalities Commission report and the Reid Foundation paperi, show how this can be done.


    Local government can make a huge contribution towards a healthier Scotland. Both directly through the services they deliver and in partnership with the NHS and others. They can bring the authority of local democratic accountability to a wide range of services.

    When we focus on the social determinants of health, rather than the medical cause of some specific disease, we see that local government services are health services. Without local government, adults and children would die sooner, would live in worse conditions, would lead lives that made them ill more often and would experience less emotional, mental and physical well-being than they do now.

    However, strengthening the role of local government won’t happen by accident. Councils need to adopt health strategies that focus relentlessly on tackling health inequalities. And the Scottish government must stop slashing council budgets to enable councils, and better distribute resources based on socioeconomic deprivation to enable them to deliver their full potential to tackling inequalities in health and wellbeing. Health inequalities will not be eliminated unless we seriously address the social determinants of health – that is where local government must play a key role.

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    NHS funding is not keeping pace with increasing demand and the needs of an ageing population. NHS boards are facing an extremely challenging financial position and many had to use short-term measures to break even.

    That’s the key message in a report that makes grim reading from Audit Scotland on the NHS in Scotland. Although Scotland’s health budget increased by 2.7% in real terms from the previous year, it is not keeping up with growing demand.  Between 2010/11 and 2014/15, the annual percentage change in the total health budget has been less than 1% and below the UK inflation rate. Health inflation is generally higher and is estimated to be 3.1% in 2016/17.

    A good example of this is drug costs. Spending increased by over 10% between 2012/13 and 2014/15 and it is predicted to rise further by 5 to 10% each year.

    Audit Scotland has helpfully highlighted a point about routing social care funding through the NHS that UNISON made when the Scottish Government published its plan. When social care money is deducted, the remaining £12.6 billion of the NHS budget equates to a 0.3% real-terms reduction in the revenue budget. As one health board director of finance put it to me, “I cannot spend every pound twice.  My English counterparts get the same increase, but they don’t have to fund the extra demands on social care as well”. That is not to say that social care isn’t the right priority given the huge cost to the NHS of delayed discharges. However, it does mean that the NHS in Scotland isn’t getting the resources it needs.

    The report also shows that many health boards are struggling and the books are only balanced by payments from the Scottish Government and savings plans, many of which are not recurring. Short-term measures don’t deliver long-term financial viability. The total savings that boards are aiming to make has increased by 65% in real terms, from £293 million in 2015/16 to £484 million in 2016/17 (£492 million in cash terms). By any standard this will be extremely challenging.

    Audit Scotland rightly suggests that NHS boards need to look at reorganising acute services to free up more resources for investing in community-based facilities. However, they recognise that boards are often faced with considerable public and political resistance to proposed changes to local services. The SNP government will find it difficult to challenge this opposition when they ran similar campaigns when in opposition.

    NHS boards continue to find it difficult to meet key national performance targets. Overall NHS Scotland failed to meet seven out of eight key targets. The only standard met nationally was the drug and alcohol treatment standard, although it was close to meeting the cancer target.

    Staff costs are the largest spending area in the NHS. In 2015/16, they were £6.2 billion, accounting for around 55% of total revenue spending. This is an increase of 6.4% in real terms since 2010/11. £175 million was spent on agency staff. Spending on temporary staff increased from 1.6% of total staff costs in 2012/13 to 2.8% in 2015/16. The average cost of salaried nursing staff was £36,000 per WTE, agency nursing staff cost more than twice this, at £84,000 per WTE. The report highlights risks to patient care from high use of temporary staff.

    Staff turnover was 6.4%. Nursing and midwifery vacancy rates were 3.6% overall, 9% for health visitors. There are significant variations between boards. 5% of GP practices (49) are now being run directly by their local NHS board.

    The Audit Scotland report is required reading for anyone concerned about our NHS. It clearly shows the increasing demand on services and the challenges in reforming the system. Most of all it shows that the NHS is underfunded, not overspending, and staff are under intolerable pressure to bridge the gap.

    This is from the SHA Scotland blog

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    I had a nasty experience a couple of weeks ago. I was booted out of the Royal College of Nursing congress in Glasgow while distributing flyers promoting my Parliamentary Petition calling for a whistleblower hotline for NHS staff. The nurses were interested- my flyers went like hotcakes- but after 30 minutes I was told to leave by RCN Scotland officials insisting the call for a hotline conflicted with RCN policy

    Whistleblower nurse Danni Gray, from Stoke-on-Trent Hospital, was incredulous that I was ordered to leave. Danni had come a cropper herself when she blew the whistle (her story is featured in the May edition of the “Nursing Standard”, Volume 30). (The picture shows her and I outside the SECC after ejection.)

    Peter Gregson and Danny Gray

    The RCN is not the only staff association that fears having whistleblowing discussed by its members: UNISON, UNITE, RCN & BMA have all refused to allow their Scottish members to discuss the petition, which calls upon the Scottish Government to establish an independent national whistleblower hotline for NHS staff to replace the current helpline, widely derided as useless.

    Because health workers in Scotland are being blocked from debating whistleblowing, I have launched a second petition to support the campaign- a petition for a Petition and is addressed to the aforementioned unions’ leaders.

    The reasons unions don’t like my proposals are made clear in this petition: they give priority to relationships with NHS executive management over members well being. I aim to use public pressure to get the healthcare unions to reverse their stand and allow staff to discuss whistleblowing improvements at branch meetings.

    I am calling upon the Scottish Parliament to replace the impotent National Alert Line with an effective hotline with investigatory teeth. When staff contact the current helpline, they are referred back to their trade union or manager – which more often than not has led to either nothing happening or, worse, the whistleblower being victimised. Staff surveys found only 57 per cent of staff thought it was safe to speak up and challenge the way things were done if they had concerns about quality, negligence or wrongdoing.

    The new proposal would differ in that it would independently investigate reports about mismanagement and malpractice. It would explore perceived negligence or ill treatment of a patient by a member of staff. And bullying too: the 2015 NHS Scotland staff survey revealed 15% of staff are bullied by bosses or colleagues.

    The Petition is shortly to go before MSPs and union support is crucial to parliamentary approval. Please help me make Scotland’s health service safer.

    Sign the petition.

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    The health debate in the Scottish Parliament election didn’t inspire many in the health sector. It rarely got above the level of NHS targets and there was very little focus on health inequalities. At least the Scottish Labour manifesto led with that issue.

    As we look ahead to the new parliament there are going to be a few challenges for health. The biggest is austerity, as the SNP have largely boxed themselves into following George Osborne’s spending plans. Health spending is to increase broadly in line with the Barnett consequentials of English health spending, although the extra (and much needed) social care funding (£1.3bn) is to come ‘from the NHS’. As this is a local government function that is a big chunk out of NHS spending at a time when many health boards are reporting serious budget problems. Many suspect a number of difficult decisions have been kept under wraps until after the election.

    All the manifestos had a welcome focus on mental health services and £150m is committed in the SNP manifesto. There is another £200m for elective treatment services, although doctor’s organisations have queried the cost of this. It is a suspiciously round number! Other commitments included 500 extra health visitors – primarily for the controversial ‘named persons’ scheme; 500 advanced nurse practitioners and 1000 paramedics working in the community.

    There is at least the prospect of structural reform. The SNP manifesto has a commitment to review the ‘number, structure and regulation’ of health boards and their relationship with councils. The renegotiation of the GP contract might form the basis for a necessary shift of resources into primary care, but this won’t be easy.

    A number of MSPs retired (voluntarily!) at this election. SHA Scotland would like to pay a particular thanks to Malcolm Chisholm who gets insufficient credit as the health minister who stopped the marketisation of NHS Scotland. Our history lesson, especially for those who try and rewrite it!

    Mental Health

    Our Action on mental health services blog post welcomes greater media attention given to mental health issues. If acute services were this limited there would be a major public outcry.

    Doctors look after our mental health, but who looks after theirs? A new study reports that 60% of doctors have suffered mental illness and psychological problems at some stage of their career.

    Alliance of service providers, which support vulnerable young people, has made their own demands for fixes to what it describes as a “mental health crisis storm” in services for young people.

    NHS Scotland

    Problems with the troubled NHS24 computer system have rarely been out of the media. The latest concern is a six and a half hour training session for staff. No one listened to staff.

    Surgeons are warning that the future of six rural hospitals is ‘precarious’ due to recruitment problems.  NHS Lothian approves £25m of cuts, including 200 beds, as they struggle to tackle a £77 million funding gap against a backdrop of rising demand and an ageing population. And they are not alone.

    Pharma greed kills. The campaign that confronts big pharmaceutical companies about their rip-off prices. It threatens to ‘bankrupt’ NHS Scotland. Some progress has been made on cancer drugs, but why did it take so long?

    The government’s latest £100m to tackle cancer has been welcomed but money alone isn’t enough.

    42,021 patients were moved between Scottish hospital wards between 11pm and 6am in 2015, with critics warning the actual number is likely to be even higher. That’s what happens in a target culture.

    Public Health

    Obesity Action Scotland highlights the fact that 65% of Scottish adults are overweight, including 28% who are obese. The problem is more complex than simply behavioral change.

    Expensive health promotion campaigns have failed repeatedly because of a failure to tackle the root causes of inequality says new research from University of the West of Scotland. The people who respond best are those who are already healthy. We are ignoring inequalities and blaming the victim.

    Bowel cancer ranks as the fourth most commonly diagnosed cancer in the UK. But take up of screening is still poor in many areas. Reluctance to discuss our bowels?

    Over 276,000 people live with diabetes in Scotland, 500,000 at high risk of developing Type 2 diabetes and 45,500 living with it undiagnosed. Bellwether Report makes the case for greater support.

    Study suggests adults slumber average of 6.8 hours, missing an hour, and calls for national strategy to publicise importance of good sleep.

    Greater fuel poverty awareness could save NHS Scotland up to £80m. A perfect example of the wider impact of inequality on health.

    Social Care

    Adult social care is rarely out of the headlines. It is underfunded; it is damaging the NHS through delayed hospital discharges; it is financially crippling for users; care workers are being sold short; there are serious concerns about the quality of care; and providers say they are about to go bust. The common feature? It’s largely outsourced. Call for overhaul of system in Scotland.

    More from Socialist Health Association Scotland

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    The Central Council of the UK wide SHA has highlighted the need for more work to be done on social care as part of building a sustainable health and care system.

    The Health & Social Care Centre reports that in England expenditure of adult social services over the five year period from 2009-10 ( when the figure was £16.8 billion) expenditure has increased by one per cent in cash terms, a decrease of eight per cent in real terms. This is a reflection of the unbalanced approach to care being taken in that country.

    Our comrades in Scotland are also obviously aware of these concerns as well as judged by these comments on their dedicated SHA site which merit further consideration.

    While sound and fury explodes all around us on NHS spending, spare a thought for the crisis in Scotland’s social care system.

    Today, I was in parliament for the launch of the Commission for the Provision of Quality Care in Scotland report. The Commission was established by Neil Findlay MSP when he was Shadow Cabinet for Health and Wellbeing with the aim of reviewing how we can improve the way adult social care is delivered. It was Chaired by David Kelly who was a Director of one of the first Community Health and Care Partnerships in Scotland and brought together all the main stakeholders.

    The strength of this Commission and the earlier one on health inequalities is two fold. Firstly, they address issues that don’t get nearly enough attention in the Scottish health debate, that at times seems obsessed by A&E waiting times to exclusion of all else! Secondly, Neil was very clear in his remit that he didn’t just want another analysis of the issues (something we are very good at in Scotland), he wanted solutions. Even if the solutions might be politically difficult.

    The report starts with a stark assessment of the current position. We have an ageing population with an increase in multi-morbidity and long term conditions. In disadvantaged areas the most common co-morbidity is mental health and this combination has a strong association with health inequalities and negative outcomes for individuals and families.

    These additional demands bring with them associated costs. The report estimates a real term increase of up to £2bn per annum will be required by our health and social care system by 2025. With a small growth in the size of the overall population this is likely to place an increasing tax burden on the working age population. The recent IPPR report reinforces this point.

    During the years of Tory austerity the Scottish NHS budget has had a degree of protection at the expense of other public services including social care.This approach has failed to recognise the inextricably linked relationship between acute hospital care and care in the community. The consequences can be seen in the numbers of patients blocking beds in our hospitals and a £5million increase in the amount councils are having to generate from charging income for social care in order to compensate for the financial shortfalls.

    The report describes the complex and frankly inadequate ways the quality of care is assessed in Scotland. UNISON Scotland’s ‘Time to Care’ report starkly set out the views of care staff over the quality of care they are forced to deliver. While in the main health and social care services are provided good levels of quality, there are still too many examples of poor quality. The report concludes that general trends about quality cannot be ignored. In particular, the connection between the quality of staffing, working conditions, and quality of care is a matter of primary importance.

    The workforce chapter seeks to address a key component of this. The Commission recognises that more than anything else, the payment of the living wage and a general improvement of terms and conditions will be required to deliver a social care workforce consistent with our aspirations for quality care. This view is shared by the evidence submitted to the Commission from both trade unions and employers across the public, private and voluntary sectors. The contracting race to the bottom in care provision has to stop.

    Since the report was written the social care crisis has if anything got worse and today councils and providers in England are making similar points. We have residential and homecare providers in in very difficult financial circumstances, drawing on reserves and some are struggling to meet even day to day cash flow. Others have significant vacancy rates and increasing staff turnover. Social workers in care of the elderly teams report that it is becoming increasingly difficult to find a provider to deliver care packages in some parts of the country.

    Pay is but one element of fair work. The Commission commends UNISON’s Ethical Care Charter that includes the wider considerations that commissioners of home care should account for when contracting. These include training, induction, travel time, ending zero-hours contracts and most importantly ensuring that there is time to care.

    The Scottish Government’s standard response to concerns about social care is to refer to the new Integrated Joint Board’s that aim to provide a seamless care service. While the Commission supports this approach, it recognises that this structural change will not in itself be enough. The recent Audit Scotland report confirms this. Despite the Kerr report and much talk about preventative spending, we have not been able to break the public perception that everyone should have a district general hospital within ten minutes of their house – nor the political pressure to satisfy that thirst.

    The Commission argues that a top-down approach to the commissioning of services will fail to deliver responsive care and support. The report places an emphasis on getting locality planning right building on the knowledge and capacity of local people about their own wellbeing. It also recognises that best practice needs to be supported and rewarded. Equally, there is a need to work with poorly performing locality teams to improve outcomes. We need to recognise that not all differences in outcomes are down to differential resources. It can reflect poor leadership, organisation and bad practice.

    Housing provision also needs to change if we are to address the needs of an ageing population. All too often, a person will move from their family home into a care home via a period in hospital.This is partly because of the lack of suitable alternatives at local level. We need to build new, affordable and sustainable housing, with a range of house types and sizes that encourages mobility in the housing system and enables downsizing for those that wish it. Housing support services currently play a small, but significant, role in supporting older people to remain living at home and needs to be expanded.

    A key recommendation of the Commission is that we fundamentally rearticulate the basic social contract between the citizen and state based on the principle of reciprocity.That people contribute to the wider social good through payment of tax and direct contribution to care and support – and in return people receive high quality care and support when they need it and irrespective of their financial circumstances. This means addressing the current differences between services free at the point of use such as healthcare and some social care, but not for those under the age of 65.

    As such, the Commission arrives at a new and more robust social contract: the responsibility of the state is to ensure that citizens with personal care needs receive that care free at the point of use; and that citizens are otherwise responsible for their daily living costs and additional support requirements, funded from personal wealth or income, or for those citizens who are less well off, from welfare support.

    Finally, the Commission addresses the question of funding. A properly funded and organised social care system would actually save money. For example, a bed in a District General Hospital costs in the order of £2,500 per week, as compared with £500-£800 per week for a care home and even less for home care. The Commission points to work done elsewhere in the UK on the options for addressing the funding gap, something we have simply ducked in Scotland. A national conversation needs to be informed by a detailed examination of the spending gap and how that might be funded. The Commission makes no claim that its work is sufficiently detailed to be a definitive statement on this issue. However, they do say that it is sufficiently large that it cannot be wished away or ignored.

    The value of this Commission report is that it does more than simply analyse the scale of the problem, important though that it is if we as citizens are to grasp the importance of social care. The Commission goes much further in describing what a quality care might look like and how it should be delivered. It also doesn’t duck the need for a new social contract and the necessary conversation about funding.

    WATCH the video of Gordon Aikman to see why paying care workers the Living Wage is so important.

    Care staff in Scotland

    First published on the SHA Scotland blog
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