Agenda Pack - 24 January 2024
North Lanarkshire Council · 24 January 2024
Back to Health and Social Care Integration Joint Board — 24 January 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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A meeting of the IJB will be held on Wednesday 24th January 2024 at 10am-11.30am via MS Meetings If anyone would like to join this meeting, please contact Stacey Connor on 01698 752594 or by email at Stacey.Connor@lanarkshire.scot.nhs.uk for the relevant information. Chair: Cllr Michael McBride AGENDA No. Item Action Attachment Reporting 1. Welcome & Apologies For Noting Chair 2. Declaration of Interests Members are invited to declare any interest in relation to agenda items Board Members 3. Minutes IJB ( 22nd November 2023) For Approval Attachment Chair 4. Rolling Action List For Review Attachment Chair 5. Whole system Winter Plan 23/24 For Noting Attachment Ross McGuffie 6. Winter Resilience Update For Noting Presentation Ross McGuffie 7. National Care Service Update For Noting Attachment Morag Dendy For Noting 8. Risk Consider from the business discussed any new emerging risks to be added to risk register or whether the discussion materially alters the accessed levels of risk/risk tolerance or mitigating controls 9. Date of Next Meeting 27th March 2024 2pm-4.30pm For Noting
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1 ITEM 3 Integration Joint Board Committee Minutes from a meeting held on Microsoft Teams on Wednesday 22nd November 2023 at 2pm to 4.30pm Present: Voting Members: Councillor Claire Barclay North Lanarkshire Nominated Councillor Ally Boyle NHS Lanarkshire Nominated Non Exec Director Councillor Bob Burgess North Lanarkshire Council Nominated Councillor Phillip Couser NHS Lanarkshire Nominated Non Exec Director Councillor Paul Kelly North Lanarkshire Council Nominated Councillor Brian Moore (Chair) NHS Lanarkshire Nominated Non Exec Director Non-Voting Members: Professional Advisors Amanda Kilburn Chief Finance Officer North HSCP Ross McGuffie Chief Officer, North Lanarkshire HSCP Maddie Halliday Chief Exec, VANL Third Sector Rep Stakeholders Elizabeth Seaton Partnership for Change User Rep Officer in Attendance: Stacey Anderson Support Services Project Manager Mark Dell Communications Manager Trudi Marshall Nurse Director NLHSCP Dr Lucy Munro Medical Director NL Harry Robertson Carer Representative Dr Tyra Smyth General Practitioner (GP) Dr Josephine Pravinkumar Director of Public Health Maggs Thomson Head of Health North HSCP Rose Walker Minute Secretary Observing: Sharon Murray Associate Nurse Director (Adults) Ann McKechin Public Health Scotland APOLOGIES: Paul Carey Audit Scotland Morag Dendy Head of Planning, Performance & Quality Diane Fraser Head of Adult Social Work Services Councillor Martin McCulloch North Lanarkshire Council Nominated Councillor James Muir NHS Lanarkshire Nominated Non Exec Director
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2 Fiona Owens Audit Scotland Des Murray Chief Executive NLC Maria Williamson Interim Head of Planning, Performance & Quality Alison Gordon Head of Children & Families & Justice Services CSWO of NLC Jann Gardner Chief Executive NHS Lanarkshire Cathy McGinty Staff Side Representative NHSL Dr Kenneth Dagg Secondary Care Medical Practitioner John Watson Employee Representative NLC Unison ACTION 1. Welcome and Apologies The chair welcomed everyone to the meeting and introductions were made; apologies were as noted above. 2. Declaration of Interests There was no declaration of interest made. 3. Minutes of IJB (27th September 2023) Maddie Halliday asked that two corrections be made to the previous note of meeting, 1) attendance list; Maddie is listed as an officer; this requires to be amended to list as a non-voting member. 2) the reference where Maddie refers to the community and voluntary sector funding risk; the note documents it being currently high; this should be documented as moving to very high. The remaining minutes were approved as an accurate reflection of the discussion. 4. Minutes of IJB PFA (18th October 2023) The minutes from the IJB PFA subcommittee were noted by the committee. A correction to be made to the attendance to list Maddie Halliday as a non-voting member. 5. Matters Arising/ IJB Action Log There were no significant matters arising. Ross McGuffie provided an update on the IJB action log and noted the following key points: Item 12 Strategic Commissioning Plan - The Community Nursing review will be tabled on February 2024 agenda Items 13 Mental Health Strategy, and item 5 Risk Management Strategy where tabled at the IJB liaison session 8 November 2023, action now closed
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3 Improving Cancer Journey Board - Ross McGuffie informed the initial focus will be on cancer patients. A full update will be provided to the board. Currently have five community connector posts commenced on the 6th of November 2023. The remaining 5 posts will be recruited to in January 2024. The improving cancer journey piece of this was 3.5 full time equivalent, Ross updated through the community connector program, have expanded with a wider remit and has been moving forward with positive feedback. This has been a huge challenge in terms of the service level agreement and the data protection impact assessment work, however this is now nearing completion and will help other similar developments in future. Maddie Halliday advised have found that some of the issues are because the connectors are employed in the community and voluntary sector around data, but the SLAs required are nearing sign off. Brian Moore advised can be brought back for further discussion at a future meeting. 6. Chief Officer Update Ross McGuffie provided the committee with a general update on the following: Operation Flow - currently undertaking another round of Fire Break. The focus has been on reviewing every inpatient with 14 days plus length of stay. Review work has been undertaken across all acute sites, Hairmyres, Monklands and Wishaw. The aim of visits is to have a look at criteria to reside, to have a look at what the challenges are in terms of supporting patients back home. Have done some targeted work around care home delays and been supported by a care home liaison service. Supportive work is ongoing which has seen 70 referrals between Monday and Tuesday this week, and a further 22 planned referrals. Have reduced care home delays from 28 to 14 and are currently in the 60s in terms of delays. A self-assessment tool - has been developed and rolled out across Scotland to get a real understanding of all the sort of complexities that each system is working the way through and what progress has been made from that. Priorities identified around early supported discharge models with having a process in place across each referral practices to ensure that we are working concurrently in using planned dates of discharge. Consideration has been given to annual leave planning and making sure that we get the right staff cohort Safe Steeple exercise – This was a large resilience session held in Ravenscraig and led by the Police, looking particularly at lessons learned and from events in Manchester. Now starting to look at own operational plans Update given on recently opened new Chryston Primary school and new Health Centre; feedback has been incredibly positive on the facilities. By the month end, will be starting to move all the services that are currently in Health Clinic across into the new Health Centre and from April 2024 will start to see the Addiction, Community Mental Health teams, Physiotherapy and Sexual
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4 Health services that are currently being delivered in Glasgow moved across into the Northern corridor. Walk rounds – A programme of work is being undertaken across the Partnership with the Senior team doing two visits each month on site, ensuring we are covering all service areas over the course of the year. Ross McGuffie gave feedback on a positive walk round taken place in Motherwell; talking through some of the work around infant nutrition and our breastfeeding rates, these are still continuing to rise above the Scottish rate, acknowledged this has been great and all the work around the breastfeeding strategies between the NHS board, and the two councils is really starting to come through. Another visit to Coatbridge Health Centre provided some great examples of really integrated working with District Nursing teams, integrated Rehab teams sitting next to each other and the work that being able to do and share. Cllr Kelly acknowledged the many positives of all the progress that has been made to date, and asked in terms of Fire Break; is that something that's been put in place just to get ahead of what's expected anticipated or is reaction to the demands and the system locally? Also added in terms of supporting people back in the community, asked for an update on the vaccination program in terms of uptake amongst staff? And where we are in terms of where we think we are with COVID? Ross McGuffie responded since the October week there has been a significant period of pressure not just locally in Lanarkshire but across all of Scotland. There has been a real upturn in demand across the acute sites. Capacity is quite high at the moment; Fire break is really being pulled together for a bit of both. Through the operational flow work, there are a range of posts coming in over the coming weeks and are trying best to create as much space as possible to give the new post and new ways of working the best possible chance of success. Information on vaccination uptake will be circulated. Ross McGuffie advised in terms of COVID the levels remain quite low and asked for Josephine to provide an update on. Josephine Pravinkumar pointed out Covid and flu at base line activity as confirmed by wastewater levels. Josephine agreed to share vaccination uptake levels with the group. Cllr Burgess asked if walk rounds are there by invitation. Ross McGuffie informed the walk rounds are carried out by the senior team of North HSCP to be visible on the ground listening to staff. This is a really important piece of work in terms of having that engagement and also providing a bit of permission in terms of allowing staff to pick up their own ideas and run with them and report back. Cllr Barclay asked re the status of getting people out of hospital; how is that affecting Home Care? and at the other end is Home Care and Social Work able to keep up with the number of people who are being discharged from hospital? Is it primarily people who are not going to need any further care? Ross McGuffie advised this is one of the areas that is really quite challenging at times. Have been doing a bit of work around, the home support redesign team
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5 have been involved in carrying out a number of visits across Scotland to have a look at other models and how things are done elsewhere. Further work is coming back through IJB and the Social Work Committee in terms of developing the new model of home support. Ultimately we’re aiming to make the service as efficient as possible, ensuring we don’t over-provide or under-provide for all of our service users. Brian Moore noted acknowledgment of the intense activity in relation to managing a flow and discharges, Ross and his senior team, but also the frontline staff who are incredibly active in terms of trying to improve and continuously improve our performance and make a difference for individuals and secondly also to acknowledge appropriately the contribution Ross is making at a National level, not only in terms of feeding back from Lanarkshire, but also contributing to the national debate and solutions in terms of how we bring about more effective whole system working. 7. Frailty Strategy NHS Lanarkshire is developing a new Healthcare Strategy “Our Health Together”. As part of this development a working group was established to consider the inclusion of frailty in the strategy. The main aim for the strategy is: “Every older person in Lanarkshire with, or at risk of, frailty is supported to be healthier, to remain independent for longer and to live their best lives. All partners work together, and with older people, unpaid carers, families and communities, to prevent, detect and delay escalation of frailty through proactive, personalised, coordinated support at home, or closer to home, and age attuned integrated acute and community services.” Maddie Halliday made a couple of observations to; It would be really good with colleagues in the Community and Voluntary sector, sitting behind that strategy, maybe to document and clarify our contribution a bit more fully. Also asked a question on resources; because some of the work that you're planning is in train and committed, but whether there's challenges around on the necessary resources to achieve it? I can see that if the strategy successfully implemented, I'm sure it will be very cost effective; wondered whether was issues there. Trudi Marshall advised will link with Maddie to see how we could strengthen the reflections of the contributions to that. Josephine Pravinkumar asked around the potential of maximising the preventative elements within the strategy. Trudi Marshall advised we did look to see how we could redesign even our urgent care pathways, but there was going to be significant recurrent resource required and was not available at the time. The NHS board gave recurring funding to allow the development of a resource for a frailty TM/MH
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6 network and that frailty network which will be the building block as to how we take forward and deliver that strategy. Now in post is an Associate Medical Director and NMHAP Nurse consultant for Frailty; who will not only be looking at acute care pathways, but looking at it across the whole system wide. The group will be looking at how it implements the strategy and part of that will be looking at resource and how we really do that preventative work. Brian Moore raised question to Ross McGuffie; you previously made reference to the Tayside feedback and one of the issues was that there might be a frailty pathway that would bypass A&E and I wonder, is that a long term ambition here? whether there's an opportunity, to reframe it in terms of a whole system approach. Brian added comment in relation to the number of 450 hospital beds; in two years, three years, five years’ time, we would want to see that bed number reduced quite significantly. Ross McGuffie responded that the Tayside feedback was that frailty was one of the biggest areas of impact we could act on. Will focus as much investment as can within the Frailty agenda. Trudi Marshall added further comment to updating that Monklands has an established pathway and a Frailty unit that has been producing some good outcomes. This has never been fully funded, as in it requires a different staffing level to a normal ward; the idea is that you're wanting to have lengthy stay down at 72 days, so that high turnover, higher HP input. There needs to be work done there to make sure that we maximize in the outcomes of that unit. The IJB committee endorse Lanarkshire Draft Frailty Strategy. # 8. Getting It Right For Everyone (GIRFE) The Plan for North Lanarkshire sets out a vision for town and community hubs whereby citizens have easier and earlier access to support and services in their local neighbourhood or town. It takes a place based, whole systems approach that mobilises all assets within a community, promoting equity and increasing people’s control over their health and lives. Getting it Right for Everybody (GIRFE) provides a framework and a set of principles for person centred and community centred ways of working as outlined below: • GIRFE is a proposed multi-agency approach of support and services from young adulthood to end of life care. • GIRFE will help define the adult’s journey through individualised support and services and will respect the role that everyone involved has in contributing to collaborative care and support planning, review and personalised interventions. • Too often, adults and their families are excluded from assessment and support processes by complex bureaucracy. GIRFE is about providing a more personalised way to access help and support when it is needed – placing the person at the centre of all decision-making that affects them to achieve the best outcomes, with a joined-up, coherent and consistent multi-agency approach regardless of the support needed at any stage of life.
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7 Health & Social Care North Lanarkshire is participating the national Getting It Right for Everyone (GIRFE) pathfinder programme. The initial focus for GIRFE in North Lanarkshire is on older people and adults living with frailty, working with the Locality Planning Group to develop the approach in the Wishaw Locality. The learning from this work will inform further work across the other 5 localities Cllr Barclay added comment this is a wonderful approach and that holistic approach of getting it to the individual. Brian Moore asked; in terms of the staff engagement in the work, and the engagement plan that's in place, that it will be representative of all staff across the HSCP. Trudi Marshall advised yes; and the way that we are taking the work forward will be through the locality planning groups and the wider community networks. Brian Moore referred to other pathfinder programs looking at Frailty also, for shared learning. Trudi advised the plan is that Scottish Government is going to pull it all together and all the learning from all the pathfinders and in May 2024, a National approach based on the learning from all the pathfinders will be developed. Ally Boyle commented it brings a lot together; Impressed by the focus and, meaningful engagement, meaningful involvement in co design. Trudi Marshall advised co design work has been taking place via the community hubs and very much aligns to that wider community work and the wider community hubs where we've been getting, have started the process for Frailty through the work of community hubs. The committee agreed the following recommendations: (1) Note the participation of Health & Social Care North Lanarkshire in the national Getting It Right for Everyone (GIRFE) pathfinder programme, focussing on older people and adults living with frailty. (2) Endorse and the approach and planned work to develop GIRFE across North Lanarkshire. (3) Agree a further update on the progress of the GIRFE work to be brought back to a future meeting of the Board. 9. JRF Poverty in Scotland (2023) Report Every year at the start of Challenge Poverty Week in October, the Joseph Rowntree Foundation (JRF) publish their ‘Poverty in Scotland’ report. This year’s report considers whether ‘work is working’ for the people of Scotland. The main findings are:
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8 Over one million people still live in poverty in Scotland, with nearly half of those (490,000) living in very deep poverty. The statutory child poverty reduction targets are unlikely to be met without significant additional Scottish Government action. While the Scottish Child Payment is likely to reduce child poverty, the growth of in-work poverty is holding back further progress. Just over 10% of workers in Scotland are locked in persistent low-pay, i.e. they are paid below the real Living Wage. Of this cohort, 72% are women. Five high-priority industries play a key role in maintaining in-work poverty: retail, hospitality, manufacturing, health and social work, and the administration and support services. The report details several recommendations for the Scottish and UK Governments and provides specific findings and recommendations for the high-priority industries to work with and support their employees to make ends meet. Brian Moore advised this report is more of a national perspective on some of the key challenges and issues in relation to poverty. Maddie Halliday pointed out this is also an issue locally and advised in North Lanarkshire and across all of Scotland of 32 third sector interfaces; are launching a Fair Funding Charter, which is addressing this point around Fair Work and fair funding. Maddie highlighted in addition to the Scottish Government Fair Work Framework there is of course, the North Lanarkshire Council Employment Charter, which is also locally promoting Fair Work, which includes living wage and living hours and certainly the Council's enterprise team are actively promoting that into the business community as in commercial sector. The IJB: (1) Reviewed the main points of the JRF Poverty in Scotland (2023) report (2) Note the strategies and plans already in place across North Lanarkshire to tackle poverty (3) Discussed and consider any wider implications or areas for improvement 10. Public Sector Equality Duty The Public Sector Equality Duty came into force in April 2011 (s.149 of the Equality Act 2010). The act set out the requirement of public authorities to ensure that they meet the objectives set out under s149 of Equality Act 2010 including: Eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010 Advance equality of opportunity between persons who share a relevant protected characteristics and persons who do not share it Foster good relations between persons who share a relevant protected characteristics and persons who do not share it
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9 As part of the Equality Act 2010 (Specific Duties) Regulations 2011, public authorities are required to publish: Equality objectives at least every four years Information to demonstrate their compliance with the public sector duty These initial changes will include the delivery on two key prioritised regulatory changes around the revising of the current pay gap reporting duty and the introduction of a new duty on listed public bodies in relation to their use of inclusive communication. A decision has also been taken to repeat the current regulation 6A of the Scottish Specific Duties which relate to the collection of data on listed authorities’ members ‘characteristics’ and a consultation on the development of the Mainstreaming Strategy will also take place by the end of 2023. Maddie Halliday raised question on with the increasing use as well of the human rights and our commitment to human rights; is wondering how those two articulate with each other whether they do or not, they obviously overlap and about training around equality, human rights and of staff. Ross McGuffie responded; we are pulling this together as an integrated approach as possible, and we'll try to do that across all the partner bodies at the same time. We are take learning from between Council and NHS and IGBT together so that we come up with one overarching response in terms of training. We have got Manager training programs in place across both NHS Lanarkshire and North Lanarkshire Council for staff and around equality and diversity, so we we've got that built into the training requirements across all staff groups. The IJB noted the contents of the report which includes details of changes being made to the Public Sector Equality Duty. 11. Assistive Technology This report provides an update on the new assistive technology team within North Lanarkshire Health and Social Care Partnership and its impact since inception and aims going forward. Cllr Kelly asked in relation to referrals regarding families or individuals who are looking to get more digital help and digital assistive support; how would they be referred? Raymond Taylor advised referrals come in from individual teams within the Council and also self-referrals. The IJB committee approved the following recommendations: a) Note the progress of the new assistive technology team to date. b) Note the progress on promotion of digital services by the team. c) Note the uptake in technology and increase in engagement. 12. Risk Management Report The purpose of this report is to provide a summary to the IJB on risk management activity, noting any amendments or additions to the current risk register.
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10 Following discussions at the IJB Liaison Session, the last meeting of PFA on 18th October 2023 and the meeting of the IJB on 27th September 2023, the risk register has been updated and additional controls/actions added to: IJB 01/21 – Financial Challenges IJB 04/21 – Set Aside IJB 06/21 – Prescribing IJB 11/21 – Performance IJB 13/21 – Care Homes IJB 14/22 – CAMHS IJB 17/22 – Unscheduled Care IJB 02/22- Prevention, detection of fraud, bribery and or corruption There are currently two risks rated as Very High on the IJB risk register IJB 06/21 – Prescribing Activity and Costs IJB 17/22 – Unscheduled Care There are eight high rated risks on the IJB risk register. IJB 01/21 - Financial Challenges IJB 04/21 - Notional Set Aside Budget IJB 12/21 - Staff Health & wellbeing IJB 14/22 – CAMHS IJB 15/22 – Cost of Living IJB 16/22 – National Care Service IJB 19/23 – Service sustainability IJB 20/23 – Workforce sustainability The IJB currently has 17 risks identified on its IJB risk register with 10 risks rated as high or very high. Stacey Anderson informed North HSCP have discussed the risk process moving forward as an IJB and it has been decided that IJB will received the normal risk paper with the risk in focus element of it being displayed in presentation format. Updated that the risk around the ineffective Governance arrangements; the title has now been changed to prevention, detection of fraud, bribery and or corruption. The IJB and PFA and this aligns with how the risks sits on NHS Lanarkshire board as well and the home risk has also been updated to divide to reflect the overall care home position instead of a COVID position. It is based on some feedback that we had received from IJB members and the strategic and performance unscheduled care risk, and was updated to deflate the work of operation flow and the tasking finish groups. Maddie Halliday looked for clarity around the shift from governance risk to fraud and bribery and pointed out that they overlap but is not the same thing; there is still an issue around good governance which is much wider than fraud. Added does not know whether that is a high risk or even a medium risk. Maddie also looked for clarity around the funding situation for the community and voluntary
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11 sector and as often is referred to as the third sector and mentioned, it is probably moving into the very high risk. Phillip Couser made reference to looking at a number of the risks, “strike me these are issues rather than risk so prescribing for example, the issues with prescribing are here now, we are already having the issues here particularly on the cost and you pick up later on unscheduled care. Should we have an issues register and actually take those things and have an issues register rather than just a risk register?”. It was agreed this required further corporate discussions. Stacey Anderson advised this is still a governance issue, but then effective governance arrangement, the issue was with the title within the risk register because the commentary then within the discord just it was more around prevention and detection of fraud labelling corruption. And to pick up on Maddie’s other point about Increased risk level around just the voluntary sector, that's maybe something that we do at the PFA with a risk in focus so that we have that deeper discussion element. Agreed Stacey Anderson will link with Maddie Halliday to help build on that risk and focus. There was some discussion around risks not always matching between the partner bodies and the IJB. One example was Primary Care Out of Hours, where the IJB risk register still contained concerns around the loss of a North base as it was felt to be a particular risk for the NL population. The IJB note the contents of the report which includes the latest version of the IJB risk register and a note of those operational risks highlighted by the Heath & Social Care North Lanarkshire partnership that impact upon delivery of IJB business. SA/MH 13. Financial Monitoring This report provides a summary of the financial position of the North Lanarkshire Health and Social Care Partnership (HSCP) for the period 1 April 2023 to 30 September 2023. The report is based on the financial monitoring reports received from NHS Lanarkshire Director of Finance and North Lanarkshire Council Head of Financial Solutions. The position detailed in these reports is therefore based on the information contained in each partner’s respective financial systems and includes accruals and adjustments in-line with their financial policies. As detailed in the report, the IJB year to date position, prior to removal of ring- fenced funding, is an underspend of £2.323m and the projected outturn for 2023/24 is an underspend of £4.313m, assuming the current trajectory of spend continues throughout the financial year. Phillip Couser noted the workforce issues around social care, if you look at that list of whether the vacancies set, you know the social services piece is by far the
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12 largest, both the number and as a percentage, about 25% of the total. That is a huge gap? it prompts the question of what impact is that having fuel and other areas? Ross McGuffie advised this has been picked up through the Council risk process. There is significant work ongoing around recruitment with some areas of real gian, but it is taking multiple rounds of recruitment to fill posts. Brian Moore asked in reference to the risk register; there has been a lot of media focus on care home, viability over the past few days. is there any update in terms of the what the position is expected, regard to future fees, has next year's fees been negotiated yet? And secondly, the issue about a £12 an hour rate, which would be introduced in April 2024, could you advise as our letters as to what the process will be for ensuring that gets out to all providers of services and how complicated is that for yourselves? Ross McGuffie advised the negotiations for next year’s National Care Home Contract are now underway, but expected to be another challenging negotiation. The risk on the register had been reduced when the new contract was agreed, but quite likely to rise again if quick agreement can’t be reached. Amanda Kilburn added there will be a reserve strategy done again and will provide update to position in March 2024. Ross McGuffie advised that we have got a budget group formed to look at the recurring savings that were required to make. The focus is on trying to do this in line with the commissioning plan and try to do in line with the role like human learning systems. The IJB: (1) Acknowledge the contents of the report; and (2) Acknowledge the revised projected outturn for 2023/24 is an underspend of £3.640m. 14. IJB Terms of Reference Review & Future Dates The Terms of Reference for both committees were formally approved at the IJB meeting on 23rd November 2017 and membership of both committees was formally reviewed in March 2018, June 2019 and November 2020.The Terms of Reference for the IJB PFA was amended and formally approved in March 2023. Stacey Anderson noted we recommend within the ToR that the membership of the IJB is reviewed every three years. Minor amendments to the original Terms of Reference for the IJB are proposed to reflect the primary functions of the IJB and the addition of the new North Lanarkshire Health and Social Care Website. Maddie Halliday sought clarification to whether she should be listed as a non- voting member, as listed as a stakeholder member. In reference to partnerships for change, understanding is that organisation doesn't exist as such anymore and
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13 also key responsibilities which are listed under Section 4; about approving the strategic plan and approving directions. Stacey Anderson noted in terms of the membership the Act prescribes a range of different groups including voting members, not voting members and a number of stakeholder groups. Brian Moore asked for firther discussion around stakeholder membership and it was agreed this would be arranged for a Liaison session in 2024. The IJB approved: The revised Terms of Reference for the IJB. Note the schedule of dates proposed for the IJB and P, F&A meetings for future meetings Approved that stakeholder membership of the IJB committee is reviewed in line with the IJB membership guidance that all IJB members (apart from Chief Accountable Officer, Financial Officer and Chief Social Work Officer) are appointed for three years unless their membership is terminated earlier. Membership can be renewed for further periods of three years at a time or a new member appointed 15. Committee Draft Work Plan The draft work plan with the committee to provide an oversight of reports planned to come to 2024 scheduled dates. The work plan is derived from the responsibilities and information requirements set out in the IJB Committee Terms of Reference. Should these change as a result of a further review of committee roles, the work plan will be revisited. The committee noted the plan. 16. Updated Integration Scheme The Public Bodies (Joint Working) (Scotland) Act 2014 (thereafter known as the “Act”) requires Health Boards and Local Authorities to integrate planning for, and delivery of certain adult health and social care services. The Integration Scheme sets out the agreement through which NHS Lanarkshire Health Board and North Lanarkshire Council do this. The updated Integration Scheme and associated paper was presented to the IJB PFA in Oct 2023, the IJB PFA requested terms referencing to the IJB PFA be standardised, terms should reflect current voting members and also to ensure language is reflective of current position. Therefore, the Integration Scheme has been updated in line with this feedback. It will now be approved by NLC and NHSL before going out for public consultation.
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14 Maddie Halliday asked around going out for consultation; what is the time frame? Ross McGuffie advised 4 weeks. It will be put on the website and do something on social media to ask for comments. Brian Moore advised that the updated final version will be brought back to a future meeting for final agreement, though approval sits with the two partners bodies. Recommendations agreed by the committee: The IJB acknowledge the refresh of the IJB Integration Scheme Will provide any further comments and feedback regarding the Integration Scheme. 17. SCCG HQAIC Report The arrangements for Support, Care and Clinical Governance within Health and Social Care North Lanarkshire (HSCNL) build on well-established prior arrangements within NHS and NLC but bring processes together to receive assurance from both Health and Social work clinical services. The group meets bi monthly and works to a work plan to allow service areas to report in routinely and to offer assurance. Part of the governance framework for the group it to provide a 6 monthly and yearly report to the HQAIC. Brian Moore referred to the report, if there were to be a significant event and that adverse event in social care, in the Home Care service, how would we know about it? Dr Lucy Munro responded there is a number of reporting and committees on the social work side and it is difficult to write one report that will serve all of the purposes and I think that there may be a place for potentially having some clarity of what the work plan is in terms of when the reports come in rather than you simply receiving the biannual report to see that work plan what's going where and when. Also I think it's probably utilising the tracker as being helpful. This can give assurance that all of these things are being looked at and going to the right places, but the starting point is to get the biannual report. Brian Moore added the IJB doesn’t necessarily need all the detail, but we need to know that the processes are in place and reporting is taking place. The committee noted the update from the Support Care and clinical governance committee. 18. Climate Change Report – Stacey Mandatory reporting legislation in relation to Climate Change came into force in 2015 with the IJB, as a public body, required to report annually on compliance with climate change duties. The relevant legislation is the Climate Change (Duties of Public Bodies; Reporting Requirements) (Scotland) 2015 and the associated amendment order of 2020.
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15 North Lanarkshire IJB has complied in full with reporting requirements since the enactment of the legislation. Further guidance specific to IJBs was issued by the Scottish Government for the 2022-2023 reporting period. This guidance relates to areas that NL IJB report on, including the structure of the IJB and its links to the bodies it is in partnership with. There is also a requirement to report on net zero targets and climate resilience and therefore links to the reports submitted by North Lanarkshire Council and NHS Lanarkshire, the bodies with responsibilities in these areas have been made within the NL IJB Climate Change Duties Compliance report. Maddie Halliday asked does it not mean that effectively we are double reporting for the council and NHS? Secondly is that we have, under the North Lanarkshire Community Planning Partnership, the action on climate together North Lanarkshire, which includes the statutory partners and also the community and voluntary sector, and we have agreed through that to do a public facing summary report of progress that the public sector and making around net zero. Also I think to have more of a conversation around how health and social care contributes to and certainly in the Community and voluntary side of health and social care, we're doing quite a lot to engage the public and the Community and voluntary sector. I think it would be helpful to have maybe a discussion on that maybe at the liaison meeting that's sort of join up the dots a bit beyond the formal reporting. Stacey Anderson responded having looked back at the historical notes that has been fed back to Scottish Government, it has almost tripled reporting. It is inevitable that IJB reporting will bring with it a level of duplication from the partner body reports, but it’s a legal requirement for us to do so. Tyra Smith asked Is there an easy way for people to escalate their concerns or their issues; do we have an easy route for people to be able to report things that they are perhaps aware of might be a risk or struggling to? Stacey Anderson advised that North Lanarkshire Council report on their website, Stacey to share the detail of the key email addresses for raising ideas concerns around climate change within Health and Social Care Partnership. Recommendation agreed that the IJB review and agree the content of the Climate Change Duties Compliance Reporting template for 2022-2023 prior to its submission SA 19. Risk There were no new risks identified by the committee. Brian Moore pointed out that Phillip had mentioned the social care workforce issue. This may be something we will revisit in terms of our risk register. Stacey Anderson took action to do risk and focus session. SA 20. Date of Next Meeting
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16 24th January 2024, 9.30am-11.30am
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1 ITEM 5 North Lanarkshire Integration Joint Board 2023-24 ROLLING ACTION LOG NO DATE ITEM NO DESCRIPTION ACTION BY ACTION & PROGRESS DUE DATE COMPLETION STATUS 1. 22.6.22 Item 12 Strategic Commissioning Plan M Dendy/T Marshall Detailed report on community nursing to be brought back to future meeting and included within SCP On March 23 IJB agenda. Strategic Commission Plan Approved by IJB Feb 2023. PoW on Sept 23 agenda Report to be tabled at Feb 2024 meeting 2. 31.8.22 Item 6 IJB Self-Assessment Report R McGuffie Consider hosting a development session to further explore the self-evaluation work Ongoing – future Liaison session topic 3. 14.2.23 Item 13 MH Strategy R McGuffie Consider dedicating liaison session for a more in- depth discussion Discuss wider thematic work with Brian Moore and Cllr Ayeshah Khan IJB Liaison session 8th Nov Discussed at the IJB Liaison session 8th November – Closed
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2 4. 14.2.23 Item 5 Risk Management Strategy R McGuffie A review of the IJB Risk Management process following the introduction of the new Risk Management Strategy Winter plan will be reviewed in line with risk register May 2023 Planned for Nov IJB liaison session Discussed at the IJB Liaison session 8th November – Closed 5. Improving Cancer Journey R McGuffie Bring back a further update to the Board on the roll out of the programme and
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1 REPORT Item No: 5 SUBJECT: Whole System Winter Planning 2023/24 TO: Integration Joint Board Lead Officer for Report: Ross McGuffie Author(s) of Report Report content was developed by Craig Cunningham, Head of Commissioning and Performance, South Lanarkshire Health and Social Care Partnership and Kirsty Orr Head of Planning and development, NHS Lanarkshire. . Refreshed for North Lanarkshire IJB by Stacey Anderson DATE: 24 January 2024 1. PURPOSE OF REPORT For approval ☐ For endorsement ☐ To note ☒ This paper is coming to the IJB to provide an update on and confirm support for the planning arrangements being put in place to ensure Health and Social Care Services are prepared as reasonably as they can be for the coming winter months – with particular recognition of the uncertainties and potential impacts that still remain relating to inclement weather, Covid 19, influenza, financial pressures, cost of living issues and other concurrent risks against the backdrop of major pre- existing system-wide pressures 2. ROUTE TO THE BOARD This paper has been:
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2 Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐ This paper has been prepared by the multi-agency, multi-disciplinary winter planning group alongside the key action areas of Operation Flow 2 and reviewed by PPRC and NL H&SCP SLT. 3. RECOMMENDATIONS 3.1 The IJB is asked to: note the extensive planning undertaken to date; the range of ‘early warning systems’ in place to seek to identify any issues and mitigate accordingly; and the variability of a series of scenarios which mean that the winter plan will require to be constantly reviewed and flexed to meet any emergent issues. 4. VARIATIONS TO DIRECTIONS? Yes ☐ No ☒ N/A ☐ 5. SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 Annual ‘whole system’ planning is undertaken in preparing Health and Social Care Services in such a way as to mitigate the risks normally associated with winter. The Lanarkshire Health and Social Care system – in common with that across Scotland - continues to face significant challenges. Last winter, health and social care services and staff had to contend with some of the most extreme winter pressures ever known, many of which continue to be issues for the system. 5.1.1 Planning for Winter 2023/24 commenced in August 2023 and, as in previous years, is undertaken in accordance with national guidance. The Lanarkshire approach to winter planning is a multi-agency approach across NHS Lanarkshire, North and South Lanarkshire Integration Joint Boards (IJBs) and both Councils together with the respective supports (for example, the Scottish Ambulance Service and NHS 24).
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3 5.1.2 Given the level of unpredictability in the Health and Social Care sectors as well as in the wider public system, this year’s Winter Plan has been developed as – and should be understood to be - a dynamic plan and one that is highly likely to be subject to change over the coming months. This has also been recognised from a Local Resilience Planning (LRP) perspective and a specific exercise was undertaken on 9 November 2023 to test system-wide planning. 5.1.3 Additionally, work undertaken last year by NHS Lanarkshire to take account of the increasingly likely eventuality of a number of concurrent risks which may well align to create increased system pressure has also been utilised as part of the wider winter planning process. These risks include, inter alia, further waves of Covid 19; increased prevalence of flu and other respiratory infections - both in relation to infectivity and impact; uptake and efficacy of vaccination programmes; workforce shortages in all sectors and grades across the Health and Social Care sector; public health impact of cost of living crisis/fuel costs and subsequent demand on health and care services; inclement weather and available finances. 5.2 National Guidance / Scottish Government Correspondence 5.2.1 On 22 August 2023, Scottish Government hosted a national Winter Resilience event which highlighted a range of examples of good practice that could be considered as part of winter planning. The vast majority of these examples related to supporting good system flow all year round and many are already in place in a Lanarkshire context. There was however learning from the event which has been built into the Lanarkshire plan for 2023/24, including areas of work associated with system flow and support for additional care in a community context, thereby reducing reliance on hospital care. 5.2.2 A self-assessment relating to preparing for winter was also undertaken by the multi-agency group and duly submitted to Scottish Government on 22 September 2023. 5.2.3 National guidance was subsequently published on 24 October 2023 which set out the national expectations for those areas that local winter plans would be expected to address. 5.2.4 At the winter planning meeting of 17 November 2023, colleagues from Public Health Scotland shared a set of data on anticipated additional bed pressures on the basis of current/anticipated demand associated with prevalence of influenza, Covid and other respiratory illness as currently predicted. In turn, this will be monitored to capture any revisions and also sets a useful indication of the additional beds that may be required to support the system at peak periods. 5.2.5 Some funding has been made available centrally in 2023/24 to support winter planning as well as some monies managed internally as part of the respective financial plans to anticipate winter pressures. Following discussion between the NHS Lanarkshire Director of Finance, the two Chief Financial Officers of the IJBs and Council Finance colleagues, funding to manage the impact of winter
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4 and ongoing pressures has been identified and further detail is set out at item 7 below. 5.3 Approach to Winter Planning 2023/24 5.3.1 Whilst the winter plan will be a Lanarkshire wide plan, it is being structured in two main parts for 2023/24. This is to recognise the significant work underway currently as part of Operation Flow 2 – which is aimed at maximising flow through acute hospitals and associated care pathways. Continuation and emphasis of particular aspects of this work will form the basis of the winter planning for acute hospital services. 5.3.2 All other aspects of the Lanarkshire wide winter plan will be undertaken in the normal way via the multi-sectorial/multi-agency winter planning group. Representation from acute services/Operation Flow forms part of the wider group to ensure all necessary synergies are recognised and planning is appropriately integrated. 5.3.3 As well as the national guidance referred to at 3.4, there was also a debrief of the winter plan for 2022/23 and this also features as part of the planning for winter 2023/24. 5.4 Acute Services/Unscheduled Care Winter Planning through Operation Flow 2 – including ‘power up’ 5.4.1 As reported to the Health Board at its October meeting, a system wide Operation Flow Pause Event was held on 29 September 2023 with managerial, operational and clinical leaders from across the system. The objective of the session was to provide space and time to consider if the plan aligned with needs, informed by learning from the peer review visit from colleagues from NHS Tayside. This included reassessing and confirming that the plan has the capability to deliver a better Winter for both patients and staff. 5.4.2 To enhance patient safety and staff well-being, the three priority areas agreed as continuing to underpin Operation Flow were noted to be: Managing Demand across our system Maintaining a positive admission and discharge balance Maximising Outflow 5.4.3 Creating the right conditions for the success of the winter plan is essential. Consequently, preparation has included finalising new care models and ensuring that the full workforce is engaged in all elements of the plan and understand their role in its implementation. System readiness is also underpinned by the delivery and implementation of the detail of the site and HSCP level improvement plans. This focused preparation period – ‘Power up’ – has ran through the month of October. 5.4.4 The actions that have been progressed to support Power up have included:
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5 Testing the REACT processes as part of the new Front Door Target Operating Model to increase streaming of patients to the right part of the system in UHH and UHW. The testing has helped to ensure that processes are tested and staff confidence is increased prior to Go Live Maximise the availability of Senior Clinical Decision Maker in the Flow Navigation Centre as part of the new care model to support direction of patients to the right place and at the right time. The new care model was launched on 1 November 2023 Increase ‘Near me’ consultation and ‘Call before you Convey’ between Hospital @ Home and SAS to increase efficiency and capacity within the service Completing the bed base modelling for UHW and UHH sites to inform future planning and consideration of reconfiguration of the bed base to manage demand Undertaking focused improvement work within Medicine for Older Adults – UHW to maximise flow across the acute site and offsite beds Fast tracking access to interim care beds at Cumbernauld Care Home to create acute capacity Undertaking a review of all inpatients categorised as Hospital Based Complex Clinical Care (HBCCC) to determine if appropriately coded and placed or if another care location is more appropriate to meet their needs 5.4.5 The actions outlined above are aligned to the Acute sites and HSCP based improvement delivery plans and the remaining actions being progressed through the task and finish group structures. 5.4.6 As part of the ‘Power up’ plan, all patients who have been inpatient beyond, seven, 14 and 21 days will be reviewed to assess if alternative care options could be provided and, in turn, to assist in decompressing the respective hospital sites by accelerating discharge when safe to do so. 5.4.7 There will be continual oversight of flow through the Executive Flow Oversight Board on a weekly basis, utilising all appropriate data as well as multiple daily reviews of system operating issues and the necessary actions being agreed. 5.5 Discharge Without Delay 5.5.1 Work continues in the enactment of the Discharge Without Delay programme and its related aspects, e.g. embedding of Planned Date of Discharge; consistent roll out of Home Assessment Team (North) and Home First (South); increased numbers of people being supported to die at home via ‘pathway 4’ and further work with third sector providers. 5.5.2 In particular, work being undertaken by the Home Assessment Team in North Lanarkshire has also made significant improvements in the number of people able to be supported out of hospital with no/little delay.
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6 5.5.3 Similarly, through the development and embedding of the ‘Home First’ model in South Lanarkshire HSCP, additional capacity is being created to support the review of the Care at Home service. 5.5.4 Both of these services are now seeing an increase in the number of people who are being supported to be rehabilitated to a level of being able to manage their own care independently or, in some instances, with a reduced level of care than may have been originally assessed when in the hospital or first referred. 5.6 Social Care Provider Sustainability 5.6.1 Independent providers of social care in Scotland – notably care homes and care at home providers – have highlighted the extremely difficult operating environment. As well as the cost-of-living-crisis and the lasting impact of measures introduced during the management of the pandemic, vacancy pressures also continue to be a concern for a number of providers. 5.6.2 Both HSCPs and their respective Councils have taken steps to augment their scanning of the care home provider environment and provide additional support proportionate to the demands on in-house provision, available resources (noting the social care workforce challenges) and statutory/legal parameters. On a Lanarkshire-wide basis, support and quality assurance for Care Homes continues on a whole system basis to be overseen by the Pan-Lanarkshire Care Home Assurance Tactical (CHAT) Group; and for Care at Home Services through the equivalent Care at Home Oversight Group. The Care Inspectorate participate in both of these meetings. 5.7 General Practice and pharmacy opening 5.7.1 As in previous years, a local enhanced service to support general practices opening on the fourth day of the weekend/public holidays – that is, on 26 December and 2 January, as well as the Saturdays through January 2024 - has been offered and around 60% of practices are participating in this at one time or another throughout the period. There will also be an extended public holiday pharmacy service available to ensure that people can both access prescriptions as well as being available for re-direction from NHS24, the Primary Care Out of Hours (PCOOH) Service, Emergency Departments and the FNC where possible. 5.8 General Practice sustainability 5.8.1 As is recognised as the situation across Scotland, general practices across Lanarkshire are experiencing more pressure than at any point in their history. 5.8.2 This was the subject of previous presentations to the Board which included describing the work ongoing to address capacity and demand – most notably, through the Primary Care Improvement Plan (PCIP) that is reported through to the NHS Lanarkshire Board and IJB(s) as per the expectations within the General Medical Services (GMS) Contract.
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7 5.8.3 As part of the regular reporting to Government on system pressures through the winter period, there will be weekly updates on the numbers of practices where they believe they are unable to provide the full range of services that they would under ‘normal’ working conditions. This reporting process commenced on 13 November 2023. 5.9 Primary Care Out of Hours 5.9.1 For a considerable period, and similar to most Scottish ‘out of hours’ services, the NHS Lanarkshire PCOOH Service has had to manage workforce availability challenges (notably in relation to GPs); and has regularly had to contend with escalating levels of demand. 5.9.2 The new clinical model has assisted the PCOOH Service to move to a more multi-disciplinary workforce and competency-based model of care, thereby reducing the number of occasions when alternative arrangements have been introduced. This will also be enhanced over the winter period to ensure additional staff are available to manage the additional demand that can be anticipated across the peak activity periods in winter. 5.10 Contingency Arrangements for Additional Deaths 5.10.1 As set out within national guidance and is the case every year, work is underway – including with local undertakers - to ensure that there is sufficient ‘pace’ of funeral services (both burials and cremations) to support the eventuality of a significant excess of deaths over the winter period. Additional mortuary capacity identified for Covid 19 is still in place and will continue to be available over this winter period if required. 5.11 Covid 19 and Flu Vaccine Programme 5.11.1 Following final advice on the winter Covid 19 booster programme from the Joint Committee on Vaccination and Immunisation (JCVI), the following groups are being offered an additional Covid 19 booster: Residents in a care home for older adults and staff working in care homes for older adults. Frontline Health and Social Care workers. All adults aged 65 years and over. Those aged 5 to 49 years in a clinical risk group, including those who are pregnant. Those aged 5 to 49 years who are household contacts of people with immunosuppression. Flu vaccines will be available to a wider range of individuals, including all >50 year olds. 5.11.2 The programme is well advanced and take up of vaccines is on target to be consistent with national performance. In addition to this, there is a range of services designed to offer vaccines to any who are in geographical areas or part of a thematic/ethnic group where take up of vaccine is less than hoped for.
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8 5.12 Carers Support 5.12.1 Funding from the Carers (Scotland) Act 2016 allocation 2023/2024 has been used to enhance operational services for carers across both Partnerships. This included monies from this funding being directed to support ongoing work with carers, with a particular emphasis on the Self-Directed Support (SDS) agenda; and a strengthened internal capacity within the HSCPs to enable frontline staff in managing increasing demand with regards to supporting carers. 5.13 Staff Wellbeing 5.13.1 NHS Lanarkshire’s Health and Wellbeing Strategy will form an integral part of the system wide winter plan, with the emphasis on providing a working environment in all areas across Health and Social Care where staff are able to enhance and maintain their personal and professional wellbeing and to reach their full potential in a culture that provides space, time and support for self- care. 5.13.2 The Strategy supports the shared vision of ensuring that staff health and wellbeing is embedded fully and championed at all levels across the respective organisations. To increase visibility and awareness of staff health and wellbeing platforms, Staff Health and Wellbeing week was designed to showcase the support, resources, initiatives and opportunities currently provided to help support staff to manage their health and wellbeing. Again, like the wider approach to winter planning, this recognises pressures which are system-wide; and a shared approach to manage the dynamic between the imperative to maintain staff health and well-being alongside the significant demand being placed on health and social care services. 5.13.3 Council employees can also access a range of materials to support health and wellbeing through the respective employee programmes. 5.14 Adverse Weather 5.14.1 Adverse Weather events are defined by reference to the Met Office Weather Warning system. NHS Lanarkshire and both North and South Lanarkshire Councils have policies in place in relation to adverse weather that applies wherever severe weather may obstruct staff from being able to attend work, and/or where severe weather poses a significant risk to the health, safety and wellbeing of staff. 5.14.2 A series of actions is open to the organisations – individually and in collaboration - in managing adverse weather and these have been refined over many years of winter planning. These include working with and through the Local Resilience Partnership (LRP) and with pre-identified voluntary organisations.
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9 6. CONCLUSIONS A range of implementations and reviews have taken place to ensure the right conditions for the success of the winter plan. Preparation have included finalising new care models and ensuring that the full workforce is engaged in all elements of the plan and understand their role in its implementation to support continuous patient flow and care. 7. IMPLICATIONS 7.1 Concurrent Resilience Planning and Risks 7.1.1 As highlighted above, there is a potential of concurrent risks aligning to have a significant impact on the wider health and social care services. 7.1.2 Resilience Planners from across the NHS and local government have been collaborating on scoping the range and extent of the mitigating factors introduced to reduce the impact of winter on the overall system. A very well attended ‘Winter Breach’ event was held on 9 November 2023, organised by the Lanarkshire LRP and focussing on the potential disruption caused by severe flooding. 7.1.3 Importantly, there are well-developed escalation processes and prioritisation frameworks in place supported by ‘Strategic Command’ structures that can be introduced when required. These arrangements provide appropriate and necessary governance for services to be stood down in a planned way in extremis, and thereby ensure a focus on the delivery of essential/core functions and the provision of care for the most vulnerable. 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒
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10 People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) N/A 7.3 FINANCIAL 7.3.1 A number of funding sources are being utilised to cover the cost of the additional services being introduced to support enhanced staffing and services across the peak winter period. For the majority of services, they will operate from mid-December through to mid-March. 7.3.2 Funding sources include nationally provided Unscheduled Care monies; monies announced on 24 October to support additional winter planning; financial plans of both the NHS Board and the two H&SCPs as well as the potential use of some of the funding associated with Operation Flow and the attendant aspects which will be enhanced over the winter months. 7.3.3 In total, it is anticipated that circa £4.0m will be utilised in funding all the additional services which will be provided and this can be funded from the available budgets. This paper has been reviewed by Finance: Yes ☒ No ☐ N/A ☐ 7.4 RISK ASSESSMENT/RISK MANAGEMENT 7.4.1 As highlighted above, there is a potential of concurrent risks aligning to have a significant impact on the wider health and social care services. 7.4.2 Resilience Planners from across the NHS and local government have been collaborating on scoping the range and extent of the mitigating factors introduced to reduce the impact of winter on the overall system. A very well attended ‘Winter Breach’ event was held on 9 November 2023, organised by
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11 the Lanarkshire LRP and focussing on the potential disruption caused by severe flooding. 7.4.3 Importantly, there are well-developed escalation processes and prioritisation frameworks in place supported by ‘Strategic Command’ structures that can be introduced when required. These arrangements provide appropriate and necessary governance for services to be stood down in a planned way in extremis, and thereby ensure a focus on the delivery of essential/core functions and the provision of care for the most vulnerable. Relevant Risk Register Details Current Risk Level Risk Owner IJB – Unscheduled Care There is a risk that we cannot sustain whole system patient flow through peak winter pressures due to increased front door demand; hospital workforce capacity; delays in onward movement of patients due to care home capacity/outbreaks and care at home capacity; and community health and social care workforce capacity leading to reduced ability to meet 'routine' and increasing bed demand for more unwell patients, deteriorating delayed discharge performance and an inability to recover services. High Ross McGuffie 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken.
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12 Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes ☒ Provide stakeholders with information on how to get involved ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☒ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff □ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.5.1 Work is underway at both local and national levels on the public messaging in relation to the different pathways/routes into health care services the public are being asked to follow during the winter months. As will be appreciated from the foregoing range of initiatives, there are many areas where the public will be asked to assist in managing the impact of winter this year. South and North Lanarkshire HSCPs, both Councils and NHS Lanarkshire are actively involved in seeking to ensure the messages are appropriate, shared widely and understood. 7.5.2 The key message themes are to ask people to plan ahead; know the different options that are available to them to access urgent care; and to encourage as many people as possible to access the service which is closest to them and least reliant on hospitals and general practices. Communication staff from both Councils are also actively engaged in the advertising campaigns to maximise care staffing recruitment. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY
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13 EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes ☐ No ☐ N/A ☒ EQIA added to website: Yes / Date added ☐ No ☐ N/A ☒ 8. BACKGROUND PAPERS Appendix 1 Health and Social Care Winter Preparedness Plan 2023-24. 9. APPENDICES Please include a glossary of terms if not already included. None. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following;
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14 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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15 Appendix 1 Health & Social Care Winter Preparedness Plan 2023/24
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16 Contents Joint Foreword by Cabinet Secretary and Councillor Kelly .......................................... 3 Introduction ................................................................................................................ 5 Our Principles and Priorities for Winter 2023/24 .......................................................... 6 Learning from Last Winter ............................................................................................ 7 A Different Approach ..................................................................................................... 8 Working in Partnership ............................................................................................. 8 Improved data collection and reporting..................................................................... 8 Winter Summit ........................................................................................................ 9 Winter Preparedness Checklist ............................................................................... 9 Priority One. Ensure people receive care at home, or as close to home as possible, where clinically appropriate ........................................................................................ 10 Priority Two. Consistent messaging to the public and our staff that supports access to the right care, in the right place, at the right time ................................................... 12 Priority Three. Focus on recruitment, retention and wellbeing of our health and social care workforce .......................................................................................................... 13 Priority Four. Maximise capacity to meet demand and maintain integrated health and social care services throughout autumn and winter .................................................... 15 Priority Five. Support the delivery of health and social care services that are as safe as possible throughout the autumn and winter period, including delivery of a winter vaccination programme for Covid-19 and flu .............................................................. 17 Priority Six. Work in partnership across health and social care, and with other partners, to deliver this Plan ....................................................................................... 19 Priority Seven. Protect planned care with a focus on continuing to reduce long waits. ..................................................................................................................................... 20 Priority Eight. Prioritise care for the people in our communities who need it most. .. 21 Summary and Escalations .......................................................................................... 23
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17 Joint Foreword by Cabinet Secretary and Councillor Kelly There is no doubt that this winter will present considerable challenges to people who need to access our health and social care system, which is why the planning cycle for this winter has started earlier than ever before. The Scottish Government and COSLA have been supporting the system to be as ready as possible for the pressures it will face since the end of last winter, so that people can continue to access health and social care services and support when they need it most. We expect an extremely pressurised winter, and local systems are preparing to work flexibly and responsively to prevent issues and address them as they arise, working across boundaries with the voluntary and independent sectors, and, vitally, with individuals, their families, carers and communities, to meet need and maximise impact. We continue to see a change in the demand for health and care services: our population’s needs are increasingly complex, and more complex personalised care is required at the point of discharge from hospital and onwards to a care home or their own home with support. This sits alongside the increase in patients we see every winter with respiratory illnesses such as flu and RSV, and weather-related injuries from falls and accidents. We are experiencing significant recruitment and retention challenges across the health and social care workforce. And of course, the potential for a rise in Covid-19 cases informs our thinking and scenario planning. This plan recognises the interdependence and integration of health and care services and seeks to ensure that people in Scotland receive safe and timely access to health and social care services and supports over winter. We have significantly strengthened our efforts to support the system in its planning and preparations for the inevitable challenges this coming winter will bring. Local systems are assessing their own readiness and will take decisions both to prevent and to address pressures as they arise. This plan aims to support local systems to, when needed, make changes, at pace, to relieve pressure and drive improvement, to provide the best levels of care possible for the people we serve. However, there is also a recognition that at times, we will need to prioritise care and support for those most in need, particularly when levels of demand and need rise. This Winter Plan sets out the actions we know from previous winters work to help relieve pressure points across the system. We believe the principles and measures set out in this Winter Plan are the right ones. Critically, we are encouraging the system to adopt a ‘home first’ approach when it is clinically appropriate to do so. Providing care in a home setting is better for people, and better for their families and carers and also frees up capacity in our hospitals. We are providing the conditions for the system to do this. For example, the Scottish Government is significantly increasing investment in hospital at home, an initiative providing acute care at home which has consistently delivered improved levels of patient satisfaction compared to in-hospital care. We are united in our resolve to deliver for our citizens, and the Scottish Government and COSLA have been working tirelessly to create the conditions needed for the whole system to deliver. This Winter Plan forms the basis of a joined-up and collegiate approach to increase resilience, reduce pressure and improve outcomes for our citizens across the complex landscape of health and social care.
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18 Michael Mathieson Councillor Paul Kelly Cabinet Secretary for NHS Recovery, COSLA, Health and Social Care Health and Social Care Spokesperson
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19 Introduction This Winter Plan represents a whole system approach to responding to a surge in demand for health and social care services. While the focus of this plan is on the winter months, the measures outlined are applicable to other times of the year when our health and social care system faces increased pressures. We are encouraging systems to adopt a preventative approach as far as possible to mitigate and reduce harm by ensuring people who need health and social care services are receiving the right care, at the right time and in the right place. Whilst this plan provides a national overview, in developing this plan we recognise the important contribution of the voluntary and independent sector locally in delivering care and acknowledge that these services are commissioned through local arrangements. This Plan seeks to address the specific operational pressures experienced across the health and social care system over winter. We have engaged with the independent and voluntary sector as partners and leaders in the delivery of social care across Scotland. Alongside partners, the Scottish Government and COSLA continue to discuss the creation of a National Care Service which will deliver improvements for people accessing community health and social care support. Although the health and social care system is well-used to planning, preparing and delivering care ahead of and throughout winter, we have strengthened our approach this year to reflect our experiences over the last few years. In doing so, we are embedding the following key components to support a more resilient health and care system better aligned to meeting people’s needs by: Whole system focus and oversight, recognising the critical interdependencies across the system. Earlier engagement and planning for winter than ever before. Having an approach that acknowledges and responds to pressures across the whole system. Implementing lessons learned from 2022/23 and previously. Supporting local systems to develop their demand and capacity plans to identify current and future requirements to support surge response. Developing a national target operating model with key resilience measures and a clear understanding of the impact that improvement work will have to achieve our targets. Taking action on returns from a preparedness checklist for local systems, ensuring we have a clear understanding of risks to the system both locally and nationally Improving data quality and reporting to support local and national assurance and understand when escalation is appropriate. Targeting interventions where there is greatest need. Utilising proven digital tools to maximise capacity. Providing the conditions needed for a ‘home first’ approach.
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20 Our Principles and Priorities for Winter 2023/24 We have developed a set of planning principles and priorities to guide our health and social care services as we put people at the heart of what we do, whilst we build our resilience to meet changing demand, recognising that surges can occur at any time of the year and not just winter. In developing our priorities, we have reflected on our approach in previous years and sought to build on what we know works, and stopped what has failed to have the desired impact, whilst strengthening our approach to both planning and delivery of the plan at a national level. In particular it is important for us to maintain a whole system focus given that people do not differentiate between the organisational boundaries in which each individual system operates, and given the knock-on impacts pressure in one part of the system has on others. By ‘whole system’, we mean every interface between an individual and the health and social care system: from pharmacy, primary care, NHS Inform, NHS 24, the Scottish Ambulance Service, to A&E and acute and community hospital settings, and on into care provided at home or in a care home setting. Carers and the voluntary sectors have a key role to play within the system. A whole system approach recognises that pressures within any area of the health and care system will impact other areas, and that any actions taken must consider this interdependency. The seven winter planning priorities, which we are empowering local systems to adopt, coalesce under three critical principles: Right care, right time, right place A partnership approach across the whole system Local and national actions we know work
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21 Learning from Last Winter Our approach this year has built on our response to previous winters, including the most recent, where we adopted a whole system approach to managing the extreme and unprecedented pressures we experienced. Last winter, we saw unacceptable waits for ambulances, queues of ambulances outside A&E, long delays in A&E departments, high levels of hospital occupancy, high levels of delayed discharge, high levels of unmet need within our communities, increased demand for GP appointments and increased demand for social care packages and assessment. Local systems, and the individuals and organisations that work within it to deliver health and care to our most vulnerable individuals – worked hard to meet high levels of demand and ensure people received care when they needed it most. However, we know that complex challenges remain and there is still work to be done to ensure people can access the care they need. To inform our approach moving forwards, we undertook a comprehensive exercise to understand the lessons learned from last winter which focused on the development, delivery, and governance of the published actions. The report makes several recommendations which have been considered and incorporated into the current winter planning work. The report highlighted that some actions and interventions had greater impact than others. However, even those with lower impact were still instrumental in building the resilience of the system to respond to surges in demand so should not be discounted. For example, Scottish Government made additional funding available for international recruitment in October 2022. We have learned that earlier communication of this intervention may have allowed local Boards and Partnerships to begin recruitment so that this could provide additional capacity in time for winter. For this year, we have worked with partners to bring forward recruitment campaigns. Critically, the report highlighted that to be effective, planning should begin much earlier and that is why this year, work began across the health and social care system in early Spring 2023. This included the launch of our Delayed Discharge and Hospital Occupancy Action Plan in March 2023, which set out a series of actions to be implemented and delivered throughout the year to build resilience and capacity in our systems.
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22 A Different Approach There are a number of critical areas where we have built upon the lessons learned from previous winters and taken a different approach to planning. Most notable of these are: Working in Partnership We have brought integrated planning into the core of preparations and have developed an extensive joint governance and assurance mechanism between the Scottish Government and COSLA. As part of this, a Whole System Planning and Oversight Group, which is chaired by Chief Executives from health boards, local authorities and a Chief Officer on behalf of Health and Social Care Scotland, has been overseeing and seeking assurance on the implementation of the Delayed Discharge and Hospital Occupancy Action Plan which sets out the interventions we know improve flow through the hospital and, vitally, improve the experience for people. We continue to support local systems to make the necessary changes to drive these improvements and to monitor the resulting impact as the actions set out in that plan are vital in reducing occupancy and delayed discharge, ultimately freeing up capacity as we head towards a period of higher demand, ensuring people and families are seen to when they need it most. The Whole System Oversight Group ensures alignment with other groups with the overall aim of improving the experience and resilience of the health and social care system. Where further assurance and escalation for joint decisions between Scottish Ministers, COSLA and the Co-Chairs of the Whole System Oversight and Planning Group on the deployment of options that support the resilience of Health and Social Care are required, a Collaborative Response and Assurance Group (CRAG), co- chaired by the Cabinet Secretary and COSLA Health and Social Care Spokesperson, will be stood up. Improved data collection and reporting We have supported local systems in the development and utilisation of data to help us better understand and respond to the challenges being experienced. As part of this, demand and capacity modelling, supported by Public Health Scotland (PHS), provides a set of resilience indicators at Board and HSCP level to enable local services to target interventions during surge responses. PHS are producing a number of scenarios for winter 2023/24 based on Covid-19, flu and additional hospital occupancy to help understand the potential scale and shape of the demand that Covid and flu may present this winter, particularly in acute hospital settings. These scenarios will be adjusted to incorporate emerging data and evidence throughout the winter. We have developed and launched two new dashboards ahead of this winter which collate data from across the whole system to give Scottish Government, COSLA and the system itself the intelligence required to inform decision-making and action. The Social Care Response and Delayed Discharge dashboard and the Whole System and Winter dashboard provide national and local level data across 25 and 35
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23 indicators respectively. Where these begin to move into below-optimal rates due to increased demand, early responses can be co-ordinated across systems and targeted interventions deployed as necessary. Winter Summit The first NHS and Social Care Winter Planning Summit, co-chaired by the Cabinet Secretary for NHS Recovery, Health and Social Care and COSLAs Health and Social Spokesperson, was held in August 2023. This Summit brought together more than 300 leaders from across the country to share best practice and local plans for this winter. Crucial to this summit was ensuring people who use our services were at the centre of our preparations. Social care providers, local government leaders and the independent sector were represented alongside NHS colleagues. The Summit generated key expert, stakeholder, and system-wide input into decisions on winter planning and preparedness in advance of responding to surges, including winter 23/24. Winter Preparedness Checklist Ahead of finalisation of this Winter Plan, we asked local systems to undertake a state of readiness check. The Winter Preparedness Checklist sets out four key areas against which we asked Health Boards and HSCPs to provide an assessment of preparedness for their local systems: Section 1: Overview of Preparedness and Business Continuity Section 2: Urgent and Unscheduled Health and Social Care, and Planned Care Section 3: Primary Care, Mental Health and Social Care Section 4: Health and Social Care Workforce and Staff Wellbeing We are now using the outputs of this checklist along with the Delayed Discharge and Hospital Occupancy Action Plan self-assessment returns and dashboard data to create a holistic system overview and provide targeted and tailored support to those areas identified as having scope to improve and increase resilience. This approach also encourages benchmarking across and within the system, and identification and sharing of best practice between areas.
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24 Priority One. Ensure people receive care at home, or as close to home as possible, where clinically appropriate Primary and community care is, for many people, the front door to the health service, where their needs are first raised. Each week in Scotland, there are around 680,000 GP consultations, with 28,000 people being seen in our hospital Emergency Departments. The Scottish Government is supporting primary care to provide essential care where it is needed most – in our local communities - with funding for multi-disciplinary teams which has been increased to £170 million this year. For many, A&E may not be the best place for their healthcare needs and our Urgent and Unscheduled Care Collaborative improvement programme offers patients alternative routes to urgent care. The ‘home first’ approach is not only better for people, but supports acute and primary care services too. This includes expanding Hospital at Home services. The Scottish Government is investing over £15 million in 2023/24 to deliver additional virtual beds this winter, significantly increasing capacity in our system and reducing the need for emergency admissions every week, and of course better for people who need acute care. Unpaid carers and social care services, alongside other community-based health and social care services, play a vital role in supporting people to live well at home. Ensuring safe, effective person-centred care through an integrated and co-ordinated health and social care approach will be critical year-round but particularly over winter. The use of telecare and digital technology to detect and alert health professionals when a person is needing support is a crucial tool, as is the ability to maximise existing community and third sector supports. Everyone in need of emergency mental health care must receive that support quickly, and wherever possible, close to home. People presenting with stress and/or distress are often conveyed to hospital when there can be community-based alternatives that support the patient as well as the system as a whole. This will also ensure that people seeking mental health support receive the right care, in the right place, at the right time, regardless of where, or what time of day they present – there should be no wrong door. The Scottish Government and local government are also continuing to maximise the use of digital tools such as increased use of Near Me in Flow Navigation Centres, Connect Me. Telecare and M365 collaboration to improve our systems and widen access, investing in Pharmacy First and community nursing teams to support people in their communities, and actively managing demand for urgent and unscheduled care to ensure that patients are triaged appropriately and directly. How we will jointly deliver this priority: Proactively support people at highest risk of hospital admission within our communities. Critical to this is the strong partnership working between Integration Authorities and local partner providers and third sector interface, as well as nationally through our engagement with sector leaders which helps us better understand and respond to the pressures and challenges facing the sector.
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25 Through the actions underway in the Urgent and Unscheduled Care Collaborative Programme, we will improve urgent care pathways in the community including enhanced links across the primary and secondary care interface. Work with NHS 24 and Boards to review alternative pathways for people with urgent care needs both in and out of hours. This could include opportunities for Primary Care Multi-Disciplinary Teams (MDTs) to provide resilience to Primary Care OOH teams to address capacity issues and divert care from A&Es, though it is important that community MDTs function both in and out of hours, to reduce unnecessary conveyance to hospital. Ensure that Community Pharmacy are able to deliver core services, including NHS Pharmacy First Scotland, both in and out of hours. Increase the use of Flow Navigation Centres to reduce avoidable visits to A&E, optimising use of Call Before You Convey and Near Me video consultations. Continue to optimise the roll-out of Near Me for social work and out of hours services. Through the SAS Integrated Clinical Hub multi-disciplinary team, undertake a remote clinical assessment of patients to care for people closer to home through self-care advice or referral to other pathways. Further expand the Hospital at Home service with an additional £3.6 million of funding to enable people to be treated at home, where appropriate, and to expand access to acute care at home with expansion of Hospital at Home to other specialty areas such as Respiratory, Heart Failure, Paediatrics and OPAT services. Involve people and their carers in decisions that relate to their care to enhance choice and control over their support. In hospital, this means engaging with the patient, their families, and carers in hospital discharge discussions to ensure their needs and wants are central to decision-making. Develop a data-based understanding of people who return to hospital upon discharge with a care package. Drive improvement through the Mental Health Unscheduled Care Network to allow people to access care in the most accessible setting.
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26 Priority Two. Consistent messaging to the public and our staff that supports access to the right care, in the right place, at the right time. To ensure that people receive the most appropriate care and are empowered to support themselves and those they care for, the Scottish Government is continuing to invest in making high quality healthcare information accessible. A multi-agency communications group provides an expert forum to agree key messages and develop national and local communications plans to ensure the public is well- informed. How we will jointly deliver this priority: All Boards, Local Authorities, Primary Care Contractors, and Partnerships to redirect and signpost people to the appropriate service for their needs, through national and local communications. Ensure the public are aware of key sources of information that will support them with their care needs, whether that information is delivered in person (for example, through social workers, community pharmacy or their local General Practice), via the telephone (NHS 24 on 111 for physical or mental health concerns) or digitally (nhsinform.scot, the NHS 24 online app, Care Information Scotland or local council websites). Messaging will focus on what a service is for rather than seeking to direct people away from a particular service. Self-management and self-care using the guides on nhsinform provide the public with an accessible resource to treat many of the common winter illnesses without the need to interact with a health professional. Communications will aim to increase awareness of these resources. Communications activity will be based on insight that has been gathered from evaluation of campaigns from previous years. Continue to build preventative messaging into health and social care communications activity for Winter (eg the vaccination programme, Mind to Mind, Healthy Know How) and throughout the year. Collaboration across national and local messaging by all stakeholders to ensure consistent messaging. Resources will be developed by Scottish Government, Public Health Scotland and NHS 24 that will be available online for any stakeholders to use through their own communications channels such as social media accounts, e-newsletters or in-venue signage to support local activation. Undertake scenario planning to identify the communication actions which can be implemented based on the level of system pressure being faced in order that appropriate messaging can be activated nationally or locally. Raise awareness nationally of the technology hubs that are located throughout Scotland where people accessing and delivering services can go to see technology in a home setting. Raise awareness that assessments for longer-term care needs should be undertaken at home whenever possible to ensure individuals get the correct level of support to maintain independence and reduce unintended harm.
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27 Priority Three. Focus on recruitment, retention and wellbeing of our health and social care workforce. Our highly skilled and committed workforce is the cornerstone of our response every winter. In order to meet demand, we must continue to focus on recruitment and retention of our workforce, ensuring that we support the wellbeing of our staff through challenging periods of high demand. We are pursuing a range of different strategies to nurture and grow the workforce in both health and social care over the long term. Within our health workforce, for example, this includes continuing to grow controlled healthcare subjects intake in line with evolving demand projections and supporting the expansion of trainee doctor posts, to reflect the changing demands on our health and social care system. Between 700,000 and 800,000 people provide unpaid care for a relative or friend at home and within other community or residential supports, and so we must also consider and respond to the wellbeing and support needs of Scotland’s hugely valued unpaid carers, as well as supporting flexible access to Self-Directed Support for people who access support and their carers. How we will jointly deliver this priority: Invest in recruitment utilising the full range of potential activity and interventions across health and social care in order to protect and maintain high quality services, including international and domestic social care marketing and recruitment campaigns. In support of retention and recruitment of the social care workforce, we will work with partners to ensure system readiness for the implementation of the commitment to enable a minimum rate of £12 per hour for those providing direct care in commissioned services from April 2024. While this commitment may not address immediate workforce pressures, it seeks to recognise the valuable efforts of our social care workforce during extremely challenging circumstances. We have also established a joint social services and social care taskforce, co- chaired by the Scottish Government and COSLA, supporting delivery and acceleration of workforce improvement activity across the social care and social work workforces. Have confirmed contingency plans in place to cover NHS staff disruption to manage the impacts, ensuring staff are fully aware of plans. Invest in local, third and independent sector organisations to support care at home teams and the wellbeing for those who provide practical support to people who are ready for discharge, and across the wider community. Raise staff awareness of digital tools available to staff that can increase capacity such as use of Near Me, use of M365 platform to safely and easily communicate, collaborate and share information, the technology hubs that are located throughout Scotland, and maximising the use of telecare devices. Continue to explore how volunteers can provide support in discharge and consider appropriate use of established local and national volunteer partnerships. Ensure people who provide unpaid care are supported in their caring roles and supported to look after their own health and wellbeing. Last winter we published the National Carers Strategy which set out the actions underway to ensure carers are supported fully in a joined up and cohesive way. It brings together existing
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28 initiatives and new approaches, and proposes new and better ways to support carers. Continue to support Boards and HSCPs to work with students and with retirees who may wish to return to work on a part-time basis to build short-term capacity as required. Support all health and social care staff appropriately in accessing the range of available local and national staff wellbeing resources and raise awareness of the mental health and wellbeing resources available on the Mind to Mind website.
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29 Priority Four. Maximise capacity to meet demand and maintain integrated health and social care services throughout autumn and winter. Both COSLA and Scottish Government recognise that actions and improvements to maximise capacity are best and most sustainably delivered in an integrated and co- ordinated way across the whole system. Local Authorities, Boards and Integration Authorities together with the voluntary and independent sectors, and indeed with communities, lead the way on integration of health and social care to deliver better experiences and outcomes for the people who access services. How we will jointly deliver this priority: Ensure consistent and effective discharge planning takes place over seven days and the holidays. Reduce the time people need to spend in hospital by promoting early and effective discharge planning deploying the basics set out in the Delayed Discharge and Hospital Occupancy Plan sent in March 2023 and robust and responsive operational management, and by recognising and meeting the challenges of unmet need in communities. The basics identified within the March Plan include: Admission avoidance. Social work input on every ward. Implementation of Discharge without Delay and Planned Date of Discharge. Early identification of complex discharges. Early engagement with people, families and carers. Implementation of discharge to assess and intermediate models of care. Daily multi-disciplinary reviews of all patients to ensure understanding of criteria to reside, planned date of discharge and early referrals for supported discharge ahead of clinical readiness date. Use of home-based assessments for all Home Support packages to ensure accurate person-centred assessments, in familiar and homely environments. This also results in more efficient use of scarce resources. Work intensively with HSCPs and Boards across the country to reduce delayed discharges for patients with learning disabilities and complex care needs moving from inpatient treatment to the community, including through supporting the use of the Dynamic Support Register, a consistent process for regularly reviewing and taking action to support individuals with complex needs. Continue to work with and support systems to ensure that suitable accommodation and support packages are in place to address delayed discharge of forensic mental health patients. Support telecare providers to increase the use of proactive outbound calling to support people who have been identified as being at risk or more vulnerable and directing them to community-based support earlier to keep them at home longer and prevent unnecessary admissions to hospital. Reduce time spent in the Emergency Department by working with Boards to deliver rapid assessment and care, enhanced triage and signposting or redirection and reduce length of stay.
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30 Make improvements to reporting and performance dashboards that will support visibility of capacity in social care, including levels of unmet need within the community and people awaiting community care assessments – and how this data impacts on the wider system. Embed use of the new dashboards to support benchmarking between systems and sharing of best practice. Work with Boards to ensure sufficient Dentistry and Optometry capacity to support referrals from NHS 24 and OOH/unregistered patient care and holiday cover. Run a mental health bed occupancy survey throughout the winter to ensure we have an understanding of service pressures and can offer support as required. Continue to support Boards to increase the use of Hospital at Home to enable people to be safely cared for in their own homes. Continue to maximise the use of Planned Day of Discharge, Discharge to Assess, Hospital to Home teams, community rehabilitation and other discharge support services.
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31 Priority Five. Support the delivery of health and social care services that are as safe as possible throughout the autumn and winter period, including delivery of a winter vaccination programme for Covid-19 and flu. Protecting people who may be most impacted by severe illness, hospitalisation or death from Covid-19 and flu, through vaccination, is a key means of protecting individuals from illness and reducing demand on our health and social care systems. We want to see as many people protected from Covid-19 and flu as possible this winter to help protect people’s health and alleviate pressure on the health and social care system. The winter vaccinations programme started on 4 September and the majority of vaccinations will be complete by 11 December to ensure protection before the main winter pressures begin (the programme will run until 31 March 2024). Scotland is the only nation offering a free flu vaccine this winter to everyone aged 50- 64 and deployment of both Covid-19 and flu vaccinations continues to be guided by advice from the JCVI. This winter programme focuses on those at greater risk of severe illness from Covid and flu; namely those aged 65 and over and those aged 6 months to 64 years at clinical risk. Priority is also being given to those who are unpaid carers. Improved demand and capacity forecasting around Covid-19, flu and underlying winter pressure scenarios is informing thinking and scenario planning to help national and local partners better understand and respond to the challenges being experienced. These scenarios will be adjusted to incorporate emerging data and evidence throughout the winter. Alongside this it will be important for us to continue to closely monitoring rates of respiratory viruses including Covid-19 and provide infection prevention and control advice and guidance as required. In addition to vaccination and infection prevention, social connections, exercise and meaningful activity are vital for the wellbeing and quality of life of everyone, but in particular those living in a care home. It therefore remains fundamentally important that people living in care homes remain connected to their loved ones even in infectious outbreak situations in line with Public Health Scotland Covid-19 Guidance. How we will jointly deliver this priority: Work with Boards to operationalise delivery of the winter vaccination programme, bringing this forward for those at highest risk where possible (care home residents, people aged 75 and over and people with weakened immune systems aged 12 and over) as a precautionary measure in light of the emergence of new variant BA.2.86. Work with partners to ensure all eligible health and social care workers, carers and household contacts of the immunosuppressed have access to their flu and Covid-19 vaccines to help build resilience within the health and social care system. Encouraging high vaccination uptake within care homes in particular is vital.
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32 Continue to work with Executive Board Nurse Directors, Chief Social Work Officers, and Care Homes to collaborate on the delivery of person-centred safe care and support to enable people to be looked after in their communities, where possible Offer children aged 2-5 years the flu vaccination from the outset of the programme to ensure they receive the earliest protection to help stop the virus spreading. To have maximum impact early completion of vaccination amongst this group is essential. Offer the flu vaccination to all school age children in Scotland. Offer seasonal flu vaccination to poultry and outbreak team workers. This is in response to the increased vigilance and monitoring of outbreaks associated with Avian Influenza. Work with Boards and wider partners to use data, along with local knowledge, to target outreach work and reduce barriers to vaccinations amongst under- served communities and where uptake continues to be lowest, including Polish, Gypsy/Traveller, African and Black/Caribbean ethnic groups and people in areas of highest SIMD. Work with Boards to vaccinate all cohorts as advised by JCVI, by 11 December. Continue to support and use demand and capacity forecasting around Covid- 19, flu and underlying winter pressure scenarios to inform thinking and scenario planning. With partners such as PHS, continue to closely monitor rates of respiratory viruses including Covid-19 and provide infection prevention and control advice and guidance as required. Continue to work with local partners to ensure family/friend visits are supported in all care settings.
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33 Priority Six. Work in partnership across health and social care, and with other partners, to deliver this Plan. To deliver on our commitments, we have put in place a national governance system with strategic oversight across health and care to recognise and mitigate evolving risks (including system pressures), maintain a flexible approach, and enable an effective response and support to whole-system winter pressures. How we will jointly deliver this priority: The Chief Operating Officer for NHS Scotland and Director for Social Care Resilience and Improvement, supported by Health and Social Care Directors and COSLA Officials, will report to Ministers and COSLA Leaders on progress of addressing whole-system pressures throughout the winter period. A Whole System Oversight and Planning Group (WSOPG) is in place and has strategic oversight of health and social care pressures through the winter period. Working on a subsidiarity basis, local monitoring will continue, and health and care organisations will utilise their established governance and response structures to manage pressures. In addition, established National Incident Management Plans will enable a multi-agency team including the Scottish Government and COSLA to assist Boards and HSCPs in responding to any emergencies or major incidents through established procedures. This will include a shared escalation plan between the Scottish Ambulance Service and NHS 24 for early identification and management of surge and risks. The third and voluntary sectors and organisations representing unpaid carers will be integral to these governance structures to assist with identification of issues and co-production of solutions.
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34 Priority Seven. Protect planned care with a focus on continuing to reduce long waits. Unfortunately, Boards have had to take the difficult decision over the last two winters to step down planned care in order to treat people requiring emergency treatment. Given the impact this has had on waiting lists, and on patients themselves, we are committed to protecting planned care throughout this winter. Following the recently set ambitious targets, Boards have made significant progress in reducing the number of people waiting more than two years for an outpatient appointment by end of August, and 10 out of 14 territorial Boards reported five patients or fewer waiting more than two years. We will continue to work closely with the Boards and HSCPs to maximise planned care capacity and where the majority of long waits in some specialities remain, ensure these are cleared as quickly as possible. How we will jointly deliver this priority: Strive to protect cancer care with a focus on continuing to prioritise new urgent suspicion of cancer patients and protect theatres for cancer operating. Work with Boards to maximise capacity through pooled lists: locally for high volume specialties (new and return patients) and regionally/nationally for longest waits/specific specialities. Maximise theatre capacity including National Treatment Centres through expanded sessions in evenings and weekends. Support Boards to maximise clinical validation of waiting lists to identify, where appropriate, alternative forms of treatment. Continue to support Boards in the adoption of Active Clinical Referral Triage (ACRT) and Patient Initiated Return (PIR) to improve patient care and reduce waiting times by eliminating unnecessary face to face attendances. Deliver the actions contained in the Endoscopy and Urology Diagnostic Plan. Encourage the optimisation of digital solutions, standardise pre-operative assessment to reduce the need for unnecessary appointments and cancellations releasing capacity. Protect planned care through maximising the use of day surgery units including increasing the proportion of procedures converted to day case surgery.
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35 Priority Eight. Prioritise care for the people in our communities who need it most. Some people are more vulnerable to the pressures and challenges brought about by winter, the colder weather, and Covid-19. We recognise the issue of poorly heated homes as a driver of poor health and almost £3bn has been allocated during the ongoing cost of living crisis to tackle poverty and protect people as far as possible. This includes £350 million this year for heat, energy efficiency and fuel poverty mitigations. Anticipatory, or Future, Care Planning aims to support people to think and plan for changes in their health and care that might happen when they are living with a serious illness, have a longer-term condition or disability that could get worse, or are getting older and frailer, focusing on what matters to them. There are a number of actions that can be taken within existing legislation and process to address pressures within health and social care services to ensure that adults with incapacity (AWI) can be discharged from hospital when medically fit and cared for in a setting more appropriate for their needs. Delays in the court system are often cited as a cause of unnecessary delay with the AWI guardianship process. The Scottish Courts and Tribunals Service (SCTS) has confirmed that there is currently no backlog in civil law cases, and that any cases relating to guardianships for AWI can be actively prioritised. This is particularly the case where input from the courts could help to facilitate moves that are of benefit to the patient. SCTS has highlighted that applying for interim guardianship orders where appropriate will enable cases to be expedited more quickly. How we will jointly deliver this priority: Relaunch the Warmer Homes Scotland scheme from October with more funding and more help for households at risk of fuel poverty to receive a climate-friendly heating system, insulation and increased energy efficiency. Direct people to the Scottish Government’s Cost Of Living website which has a range of resources including how to get in touch with your local council for help with energy and bills, and has specific advice for older people or those who are disabled. Continue to scope options for increasing creation and review of Anticipatory Care Plans (including renaming as Future Care Plans) focusing on specific population groups. Provide the Covid-19 booster for those at higher risk, as per the JCVI statement of August 2023, and explore access for older and frailer groups to receive their flu and Covid-19 vaccines in their home in partnership with local agencies and the independent sector. Continue to encourage close working with our valued partners in the independent sector, and with unpaid carers, to enable continued support for older and frailer people who may need practical help to keep them safe and well. Where necessary, local systems will prioritise social care and support services for those who need it most and are considered to be at a critical or substantial risk level.
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36 Continue to work together with Partnerships, Boards, and people with lived experience to reduce inappropriate out-of-area residential placements and inappropriate hospital stays for people with learning disabilities and complex care needs. Encourage the use of local authority applications for guardianship of Adults With Incapacity where appropriate (as opposed to private applications) and apply for interim guardianship orders where appropriate to expedite cases. We have updated the national best practice guidance for Adults With Incapacity, noting that it is and average of 91 bed days for a private guardianship application. The guidance draws on experiences of statutory partners and aims to set out for local systems models of good practice to support a reduction in delayed discharges where adults lack capacity Provide support to allow the timely discharge of Adults With Incapacity, including: o Targeted guidance for practitioners, using good practice examples, as referenced. o Proposals for reform of legal aid practice. o Ongoing training at basic, intermediate, and advanced levels for practitioners delivered on a joint basis with NES, MWC and the Law Society. o Targeted meetings with HSCPs with higher numbers of AWI delayed discharges to offer assistance and understand the local challenges to help inform any necessary national response. Increase public awareness and uptake of Power of Attorney, to ensure people continue to have their wishes and voice heard and to help enable people to be discharged from hospital as quickly as possible to the best setting for their ongoing care. Support the continued roll out of the Healthcare Framework for Care Homes that provide proactive and preventative multidisciplinary care to vulnerable individuals.
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37 Summary and Escalations This Winter Plan sets out the actions being implemented across the health and social care system in order to prepare for the increase in demand and pressure we expect to see over winter 2023/24. These actions are being adopted as part of a business as usual approach to local planning for surges in demand and complement local surge/escalation and capacity plans. To support this, we have put in place a national governance system with strategic oversight across health and care to recognise and mitigate evolving risks (including system pressures) and maintain a flexible response covering whole-system winter pressures. Working on a subsidiarity basis, local monitoring will continue, and health and care organisations will utilise their established governance and response structures.
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38 © Crown copyright 2023 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open- government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.scot Any enquiries regarding this publication should be sent to us at The Scottish Government St Andrew’s House Edinburgh EH1 3DG ISBN: 978-1-83521-434-3 (web only) Published by The Scottish Government, October 2023 Produced for The Scottish Government by APS Group Scotland, 21 Tennant Street, Edinburgh EH6 5NA PPDAS1365422 (10/23) w w w . g o v . s c o t
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1 REPORT Item No: 7 SUBJECT: National Care Service Bill Update TO: Integration Joint Board Committee Lead Officer for Report: Ross McGuffie, Chief Officer, North HSCP Author(s) of Report Morag Dendy, Head of Planning, Performance and Quality Assurance DATE: 24 January 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☐ Reviewed By: ☒ Endorsed By: ☐ By: The Senior Leadership Team. 3. RECOMMENDATIONS 3.1 The IJB is asked to note the update on the NCS Bill. 3.2 The IJB is asked to receive further updates as they are available.
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2 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 An Independent Review of Adult Social Care (IRASC) was published in February 202. The Review, chaired by Derek Feeley, a former Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland made 53 recommendations including the creation of a national care service (NCS) 5.1.2 In August 2021 consultation on a National Care Service for Scotland was launched. 5.1.3 The National Care Service (NCS) Bill was published in June 2022 and provided for the establishment of a NCS, under the responsibility of Scottish Ministers. The Bill provided for the transfer of listed social care and social work local authority functions, staff and assets to Scottish Minters or newly established local care boards/ 5.1.4 Call for Views on the Bill opened in July 2022 and closed in September 2022. The North Lanarkshire Integration Joint Board considered the response on the 21 September 2022, the link below is to the approved NL IJB response. Response 189034250 to National Care Service (Scotland) Bill (Detailed) - Scottish Parliament - Citizen Space 5.1.5 The Bill is currently at Stage 1 of the process, which aims to review the general principles contained within the Bill. The Health, Social Care and Sport Committee is the lead Committee, supported by seven others, in reviewing this stage, which is due for completion by 31st January 2024. 5.1.6 Stage 2 will then allow MSPs to propose amendments to the Bill, which will then be debated and voted on at the Lead Committee. Any amendments agreed will then be used to develop a new amended version of the Bill for publication and consideration at Stage 3. 5.1.7 Stage 3 allows MSPs to propose further amendments which will be debated and decided on in the Debating Chamber, and at this stage all MSPs can vote on them before final debate and vote on whether to pass the Bill in entirety. 5.2 Summary of Key Issues 5.2.1 The NCS Bill is currently going through stage 1 scrutiny, led by the Health, Social Care and Sport Committee. Yes ☐ No ☒ N/A ☐
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3 5.2.2 This paper provides information on two recent parliamentary updates provided as part of this Stage 1 scrutiny: 6 December Health, Social Care and Sport Committee. 11 December Finance and Public Administration Committee. 5.2.3 It is still the intention of the Scottish Government to deliver the NCS programme in line with the original commitment within the existing parliamentary session. The original proposals, however, have been reassessed to take account of the very challenging fiscal environment and as a result a phased approach to implementation is to be adopted. The Programme Business Case, which is attached at Appendix 1, sets out revised planning assumptions, based on re- profiled funding and presents a realistic approach to the delivery of the NCS. Key areas have been prioritised which are deemed to have greater impact on quality, fairness and consistency and value for money within the financial envelope available. 5.2.4 The updates to the parliamentary committees set out three main amendments sought by Scottish Government at Stage 2: That Local Authorities will retain responsibility for all current functions and the delivery of social work and social care services and there will be no transfer of staff or assets, through a shared accountability agreement; Reforming Integration Authorities (IAs) rather than creating new Care Boards and; The establishment of a National Care Service Board. 5.2.5 Scottish Government have also reaffirmed commitment to some priority areas within the Bill, including: Ability for Scottish Ministers to be enabled to provide direct funding to reformed Integration Authorities; Explore potential for independent appointment of chairs of integration authorities; Carry forward existing powers within the Public Bodies Act not yet used in practice, such as the ability to directly employ Chief Officers and other members of staff; and Continued review of arrangements for delegation or otherwise of Children’s and Justice Social Work. 5.3 Shared accountability agreement 5.3.1 Discussions with Scottish Government, local authorities and NHS Boards have been ongoing since the summer on a variety of issues. Within the proposed new national framework, local authorities and health boards will keep service delivery functions, staff and assets. 5.3.2 On 12th July 2023, an initial consensus proposal was agreed between Scottish Government and COSLA around a partnership approach that will provide for
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4 shared legal accountability, supporting national oversight as well as the maintenance of local delivery arrangements. 5.3.3 The Scottish Government now believe they can achieve the aims of the proposed Care Boards through reforming the current integration authorities. While the updates recognise there is still significant change needed at local level to bring consistently good quality services across the country, it’s important that this does not bring about widespread change just for the sake of it. Instead, Ministers intend to make amendments to the legislation which allow the Scottish Government to keep the knowledge and good work already happening in this area, whilst improving the areas in need of reform. 5.4 The National Care Service Board 5.4.1 One of the key amendments outlined the stage 2 process is the development of a National Care Service Board, which would be established as the primary means through which to secure, operationalise and manage the agreed shared accountability. This would focus on: Setting national strategic direction. Developing standards, guidance and operating frameworks. Overseeing and seeking deliver assurance on local strategic plans and ethical commissioning strategies. Monitoring system performance. Maintaining a support and improvement framework which will aim to provide support to local areas when monitoring indicates that standards are not being met with powers of intervention, when required, as a last resort. Ensuring visibility of data, information, and analysis about social care support, social work and primary and community health services through reporting on delivery. National commissioning and procurement by agreement for complex and specialist social work services which will include prison social care. Seeking assurance on public protection arrangements; and Providing support to local deliver partners. 5.4.2 Work is currently being undertaken to develop the delivery mechanism for the National Board. While this may be in the form of a public body, the final shape of the entity is still to be agreed. Following a final decision, amendment will be made to the Bill at Stage 2 to ensure the Board has the necessary duties and powers to fulfil its role effectively. The cost estimates in the Financial Implications paper have assumed the set-up of a public body to ensure that costs are represented appropriately. 5.4.3 It is expected that amendments would be introduced at Stage 2 which provides for Ministers to set out the detail and composition of National Care Service Board membership through regulations. Although it is not intended to outline the membership of the National Care Service Board within primary legislation, it is intended to include, at a minimum, an independent chair; representatives from
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5 local government to preserve local democratic accountability; the NHS and people with lived experience. 5.4.4 The National Care Service Board will be responsible for reviewing and overseeing the performance of local strategic plans. To support this, the proposal is to transfer Ministerial powers of intervention to the National Care Service Board. This will allow the Board to invoke those powers as a last resort and give it the levers needed to drive and support performance and take action if required. 5.4.5 The involvement of people with lived experience will remain at the heart of these reforms, including at decision making level by extending who on the Board has voting rights. The detail of this reform will be co-designed with people with lived experience of accessing community health, social work and social care support services, as well as unpaid carers, care providers, workforce and organisational stakeholders. 5.5 Care Boards / Reformed IAs 5.5.1 In light of the shared accountability agreement between national and local government one of the key proposed amendments to the Bill at Stage 2 is to revisit the original intention to create Care Boards, replacing this provision with the reform of current Integration Authorities (IA). 5.5.2 Scottish Government consider that amending the existing IAs would achieve the integrated reforms in a manner appropriate to the aim. 5.5.3 There are a number of fundamental areas of financial impact or risk mitigation to highlight: • Reforming current IAs rather than creating new Care Boards as public bodies will eliminate costs associated with the setup, operation and governance. This means the set up of 31 new public bodies to support the NCS is not proposed. There will be some new costs associated with the reform of IAs as outlined in the financial implication paper, but significant overall cost reductions are projected. • Statutory delivery functions will remain with local government and health boards respectively, along with assets, employment and relative funding. Consequently, costs associated with the transfer of staff and assets originally provided for will not be incurred. This significantly reduces the risks associated with asset transfer and removes risks associated with staff pensions and TUPE, previously highlighted by the Committee. • Reforming IAs rather than creating new Care Boards is also expected to significantly reduce costs associated with premises and IT. Therefore, as funding will continue to flow as per current arrangements, unless specifically agreed, this negates the concerns around VAT implications. 5.6 National Social Work Agency 5.6.1 The commitment remains to establish a National Social Work Agency (NSWA). Scottish Government and COSLA leaders will work with the key stakeholders
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6 regarding the structure and governance of the NSWA. Further information on the NSWA’s establishment will be reported to the IJB in the coming months. 5.6.2 The original objectives of the NSWA were to provide national leadership/support in: Education Improvement Workforce planning Training and development Social work terms and conditions 5.7 Children’s and Justice Services 5.7.1 The NCS Bill outlined that the NCS would be responsible for social work and social care for adults, mental health care and adult and child protection. Decisions about including Children and Justice services were to be made following further research and engagement with stakeholders. 5.7.2 A decision has not yet been taken on the possible inclusion of children’s and justice services in the NCS. 5.7.3 The Centre for Excellence for Children’s Care and Protection (CELCIS) published its final report on 13th December, aiming to answer the question “what is needed to ensure that children, young people and families get the help they need, when they need it?”. The report findings were inconclusive on the impact of structural integration. 5.7.4 A second strand of independent research was commissioned to review the best approach for Justice Social Work services, with a second strand of evidence published in December. Again, report findings to date have been inconclusive on the impact of structural integration. 5.7.5 Scottish Government have noted their continued commitment to work with children’s and justice teams and people with lived experience with the aim of understanding how best to support children’s and justice services across Scotland. 5.8 The new timeline for NCS 5.8.1 The new timeline for the NCS is outlined below: September 2024: earliest Bill enactment. Spring 2025: Shadow NCS National Board and Shadow National Social Work Agency launch. Spring 2026: NCS National Board and National Social Work Agency launch. 2028/29: NCS local reform of Integration Authorities. 2028/29 – 2030/31: Continued integration and delivery of local reform.
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7 6. CONCLUSIONS 6.1 The attached NCS Business Case, December 2023, provides more detail and information around the future intentions for the development of the National Care Service. 6.2 There are a number of changes proposed for inclusion at Stage 2 of the Bill process, which will impact on the IJB. This includes retaining and reforming the existing Integration Authorities rather than forming Local Care Boards; potential for independent chairs for IJBs; potential for direct funding for some elements; retention of Public Bodies Act elements allowing IJBs to employ staff; and importantly the shared accountability agreements supporting the local partner bodies to retain current functions and employment of staff. 6.3 Further detail will be required to fully understand the full impact of each of these elements. It is vital that throughout this process, the very positive local working arrangements between all the local partners are protected so we can continue to deliver the best possible outcomes for the North Lanarkshire population. 6.4 Further updates will be brought to the IJB as they arise. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) N/A
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8 7.3 FINANCIAL This paper has been reviewed by Finance: 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Noted below High Ross McGuffie National Care Service - IJB.16. 2022 There is a risk that the ongoing work around a National Care Service could destabilise current service delivery due to significant change activity, time demands around the co‐design process, staff uncertainty and partner organisations having to focus inwardly due to the impact of change leading to an impact on the ability to deliver the significant ongoing change programmes already approved by the IJB and the Strategic Commissioning Plan for 2023‐26 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is Yes ☐ No ☐ N/A ☒
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9 shaping and influencing service development and delivery ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership The National Care Service will have an impact on all Scottish residents. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. BACKGROUND PAPERS 8.1 Papers relating to the development and Consultation on the NCS were previously circulated. 8.2 Scottish Government NCS web pages https://www.gov.scot/collections/national-care-service/ 8.3 Policy Memorandum Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☐ N/A ☒
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10 https://www.parliament.scot/bills-and-laws/bills/national-care-service-scotland- bill/introduced 8.4 Financial Memorandum https://www.parliament.scot/bills-and-laws/bills/national-care-service-scotland- bill/introduced 8.5 Explanatory Notes https://www.parliament.scot/bills-and-laws/bills/national-care-service-scotland- bill/introduced 9. APPENDICES 9.1 Appendix 1 National Care Service Programme Business Case. Morag Dendy CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following: Morag Dendy – dendym@northlan.gov.uk
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11 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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12 Appendix 1 December 2023 NATIONAL CARE SERVICE Programme Business Case
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13
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ii Contents 1. EXECUTIVE SUMMARY ....................................................................................................................................................... 4 1.1 INTRODUCTION.................................................................................................................................................................................................................... 4 1.2 SCOPE .................................................................................................................................................................................................................................... 5 1.3 STRATEGIC CASE .............................................................................................................................................................................................................. 6 1.4 ECONOMIC CASE ............................................................................................................................................................................................................... 8 1.5 FINANCE CASE (SEE SHARED ACCOUNTABILITY PAPER) ...................................................................................................... 8 1.6 MANAGEMENT CASE ........................................................................................................................................................................................................ 8 2. STRATEGIC CASE ................................................................................................................................................................ 9 2.1 INTRODUCTION.................................................................................................................................................................................................................... 9 2.2 THE STRATEGIC CONTEXT FOR A NCS PROGRAMME ........................................................................................................................................ 9 2.2.1 Scottish Government aims and strategies ................................................................................................................. 9 2.2.2 Relevant Strategies ....................................................................................................................................................... 9 2.3 THE CASE FOR CHANGE ................................................................................................................................................................................................ 10 2.3.1 The current system ..................................................................................................................................................... 10 2.3.2 Scale of demand on the current system ................................................................................................................... 11 2.3.3 Reform of Health and Social Care in Scotland up until this point ......................................................................... 14 2.3.4 Good Practice within the Current System ................................................................................................................ 17 2.3.5 Conclusions on Scale of Demand on the Current System ..................................................................................... 17 2.3.6 Problem Statements.................................................................................................................................................... 18 2.3.7 Summary of the current case for the NCS ............................................................................................................... 24 2.4 SCOPE OF THE PROGRAMME ......................................................................................................................................................................................... 24 2.5 DELIVERY APPROACH ......................................................................................................................................................................................................... 31 2.6 WIDER STRATEGIC RISKS ASSOCIATED WITH THE DELIVERY OF THE NCS .......................................................................... 32 2.7 KEY CONSTRAINTS AND DEPENDENCIES ................................................................................................................................................................... 34 2.8 KEY INTERDEPENDENCIES FOR THE NCS PROGRAMME .................................................................................................................................... 34 2 ECONOMIC CASE ............................................................................................................................................................... 35 INTRODUCTION .............................................................................................................................................................................................................................. 35 3.1 BACKGROUND ................................................................................................................................................................................................................... 35 3.2 CURRENT SITUATION ...................................................................................................................................................................................................... 35 3.3 INDEPENDENT REVIEW OF ADULT SOCIAL CARE ............................................................................................................................................... 36 3.4 OPTIONS .............................................................................................................................................................................................................................. 36 3.5 OPTION OF BUSINESS AS USUAL .............................................................................................................................................................................. 36 3.6 OPTION OF THE NATIONAL CARE SERVICE .......................................................................................................................................................... 37 3.7 COSTS .................................................................................................................................................................................................................................. 38 3.8 BENEFITS ............................................................................................................................................................................................................................ 38 Direct benefits of the NCS .................................................................................................................................................... 38 Benefits of the NCS maximising the benefits of wider reforms ....................................................................................... 40 Wider benefits ........................................................................................................................................................................ 42 3.9 RISKS .................................................................................................................................................................................................................................... 42 3.10 NEXT STEPS/CONCLUSION ........................................................................................................................................................................................... 43 4. COMMERCIAL CASE .......................................................................................................................................................... 44 4.1 OVERVIEW .......................................................................................................................................................................................................................... 44 4.2 COMMODITY LEVEL PROCUREMENT STRATEGIES ............................................................................................................................................. 45 4.3 WORK STREAMS, FORWARD PLANNING, AND REQUIRED OUTPUTS .......................................................................................................... 45 4.4 PROPERTY REQUIREMENTS ........................................................................................................................................................................................ 46 4.5 DIGITAL REQUIREMENTS ............................................................................................................................................................................................... 46 4.6 GOVERNANCE RELATING TO PROCUREMENT AND COMMERCIAL ACTIVITY ........................................................................................... 46 4.7 GOVERNANCE RELATING BUDGETARY APPROVAL ........................................................................................................................................... 47 5. FINANCE CASE ................................................................................................................................................................... 48 6. MANAGEMENT CASE ......................................................................................................................................................... 49 6.1 INTRODUCTION ...................................................................................................................................................................................................................... 49 6.2 PROGRAMME AND PROJECT FRAMEWORK ........................................................................................................................................................... 49 6.2.1 Programme high level structure................................................................................................................................. 49
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iii 6.2.2 Appointed Personnel and vacancies ......................................................................................................................... 50 6.3 PMO GOVERNANCE AND REPORTING ARRANGEMENTS ................................................................................................................................ 51 6.3.1 Reporting Arrangements ............................................................................................................................................ 51 6.3.2 Scottish Government Internal Governance Arrangements .................................................................................... 52 6.3.3 Programme Management Office (PMO) .................................................................................................................. 53 6.4 PROGRAMME PLANNING ............................................................................................................................................................................................... 53 6.4.1 Programme Schedule ................................................................................................................................................. 53 6.4.2 Business Case approach ........................................................................................................................................... 54 6.5 CO-DESIGN ......................................................................................................................................................................................................................... 55 6.5.1 Themes ......................................................................................................................................................................... 56 6.6 BUILDING OUR COMMUNICATIONS CHANNELS AND MESSAGING ................................................................................................................ 57 6.7 MONITORING AND CONTROL ...................................................................................................................................................................................... 57 6.7.1 Risk Management ....................................................................................................................................................... 58 6.7.2 Change Control ............................................................................................................................................................ 58 6.8 PROGRAMME ASSURANCE .......................................................................................................................................................................................... 58
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1. Executive Summary 1.1 Introduction The aim of this Programme Business Case (PBC) is to define the scope and purpose of the National Care Service (NCS) programme, provide a clear understanding of what the programme is and what it seeks to achieve, where its boundaries lie, as understood at December 2023 and to support informed and robust decision making. This PBC is a live document and will continue to be developed as the Programme is further defined and in line with the Business Case Strategy a high-level extract is shown in the management case. Updates will be made to the PBC when there are significant changes to Programme scope, costs, or timeline. Revisions to the case will ensure it remains current and that ongoing consideration is given to the viability of the Programme at key decision and/or investment points. Key points will include, but are not limited to, the development of underpinning project and workstream business cases for projects that require significant funding as part of the NCS programme. Underpinning business cases as shown will provide additional detail and the opportunity for value for money to be scrutinised further before any significant investment decision. All investment in the NCS will require scrutiny as part of the Scottish Governments budget process. Programme governance will ensure that the ongoing viability and value for money for the programme is reviewed throughout the lifecycle of the programme. NCS Programme Business Case alignment to HMT Green Book Guidance In accordance with HMT Green Book Guidance, the Programme Business Case provides management with a tool for transparent and evidenced based decision making and a framework for the co-ordination, delivery, monitoring and evaluation of the resultant outputs, outcomes, and benefits. 1 The Green Book guidance is intended to be applied flexibly in line with the needs of a given Programme. This is clearly set out in HMT Green Book. • “The Green Book is not a mechanical or deterministic decision-making device. It provides approved thinking models and methods to support the provision of advice to clarify the social – or public – welfare costs, benefits, and trade-offs of alternative implementation options for the delivery of policy objectives” 2. • “The role of appraisal and evaluation is to provide objective analysis to support decision making” 3. 1 HM Treasury, Guide to developing the Programme Business Case - Introduction, page 4 2 HMT Green Book, para 1.2 3 HMT Green Book, para 1.5
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• “This guidance should be applied proportionately. The resources and effort employed should be related to costs, benefits and risks involved to society and to the public sector as a result of the proposals under consideration” 4. • “The guide provides a framework for thinking and a process for developing and gaining approval which is flexible and scalable as well as a range of tools that can be applied proportionately to provide clarity in the decision support process. It also provides a clear audit trail for purposes of public accountability” 5. “The process is flexible, because the quality and quantity of supporting analysis can be tailored to the size and complexity of the project under development.” 6A Programme Business Case should • enable the organisation and its key stakeholders to understand and influence the direction of the programme early on in the planning process. • improve decision making through early consideration of the key issues and available evidence base and assists decision makers to avoid committing resources to projects that should not proceed. • facilitate benefits realisation and risk management for the entire programme rather than a single project. • demonstrate the continuing viability of the programme to senior management and stakeholders; and • streamline the tasks and resources required for the preparation of supporting Business Cases 7. This Programme Business Case will add value to the NCS Programme through: • ensuring that the overarching financial envelope (outlined at this stage in the shared accountability document) envisaged for the lifecycle of the Programme is clear and justified, providing a funding envelope against which future requests for investment approvals can be made on a phased basis. Allowing scrutiny of proposed investment at the right time with the available evidence. • the iterative design process, which is being undertaken within the Programme, i.e. that as the Programme undertakes design work, the evidence base which justifies the investment in the Programme will grow more detailed, allowing time to co-design and test and learn. • taking stock of the case for investment in the NCS as that evidence base grows; and • having a series of ‘exit points,’ where decision makers can decide to make changes to the Programme if the case for approval to proceed has not developed as expected. 1.2 Scope This PBC reflects the progress of the NCS Programme has made to date on defining the programme, the potential benefits that may be achieved from the NCS programme, under a shared accountability model once the NCS is created and functioning. 4 HMT Green Book, para 1.68 5 HMT Green Book, Programme Business Case Supplementary Guidance, page 7 6 HMT Green Book, Project Business Case Supplementary Guidance, page 11 7 HM Treasury, Guide to developing the Programme Business Case - Introduction, page 4
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1.3 Strategic Case
The reform of community health, social work and social care has been a high-profile public policy
agenda in Scotland, over the last two decades. The plans to introduce a National Care Service
(NCS) build upon principles and ambitions that are well established, but which have not been fully
realised to date. The required level of change cannot be achieved under existing legislation and
structures. The rationale for the NCS is that the scale of transformation needed to meet aspirations
for a rights-based, person-centred system that delivers a better experience and better outcomes for
the people of Scotland requires a fundamental, system wide change and a new approach to
community health, social work and social care.
The case for reforming the delivery of integrated health and social care arose out of the Independent
Review of Adult Social Care (IRASC). Conducted in the latter half of 2020 and published in February
2021, the report concluded that whilst there were strengths in Scotland’s social care system, it
required revision and redesign to enable a step change in the outcomes for people in receipt of care,
accessing social care support. The critical role of social care, in supporting people to live well and
to have their rights respected, was further demonstrated starkly during the Covid-19 pandemic.
The challenges identified by the IRASC included:
• Inconsistency of user experience ("postcode lottery").
• Complex and inconsistent governance arrangements.
• Lack of national oversight and collaboration.
• Lack of collaborative and strategic leadership.
• The need for a paradigm shift in care support to one underpinned by rights.
• Non-integrated budgetary and financial planning.
The creation of a National Care Service (NCS) offers an opportunity to positively impact the national
economy and wellbeing across Scotland. Potential benefits will be achievable in outcomes for the
recipients of the services provided, improved terms and conditions for the workforce; and through a
greater focus on prevention, it will lessen the burden upon the wider health and social care system.
While the delivery mechanisms for the NCS may now be different, the vision for the NCS as set
out in the policy memorandum at the time of introduction remains the same:
enable people of all ages to access timely, consistent, equitable and fair, high-quality health
and social care support across Scotland;
provide services that are co-designed with people who access and deliver care and
support, respecting, protecting and fulfilling their human rights;
provide support for unpaid carers, recognising the value of what they do and supporting
them to look after their health and wellbeing so they can continue to care, if they so wish,
and have a life beyond caring;
support and value the workforce;
ensure that health, social work and social care support are integrated with other services,
prioritising dignity and respect, and taking account of individual circumstances to improve
outcomes for individuals and communities;
ensure there is an emphasis on continuous improvement at the centre of everything;
provide opportunities for training and development, including the creation of a National
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8 Independent Review of Adult Social Care (2021) (link) recognise the value of the investment in social care support, contribute to the wellbeing economy, make the best use of public funds, and remove unnecessary duplication. Table 1 sets out some of the wider strategic risks associated with the delivery of the NCS, bearing in mind that further work around the identification of risk and assessment of the likelihood and impact of these will be undertaken as part of delivering this business case. Table 1: Affordability The NCS will require significant investment, which will need to be balanced against other priorities. However, this investment is required to deliver the impactful long-term ambitions and meet future demand for health and social care services. Programme funding, which covers resourcing and additional costs, will require on-going management to ensure that budgets are effectively and efficiently used. The need for investments must be balanced against the cost to retaining the status quo. There are risks to continuing with business as usual due to the current pressures on the health and social care systems, but these risks will be compounded by the forecasted increase in demand. In addition improving the system and creating efficiencies will be likely to save money. For example, while it is difficult to fully assess the cost savings, it is estimated that delayed discharges cost the system £134 million a year. Eliminating or reducing this cost to the acute health service is not necessarily a reduction in cost to the public purse. Instead community health and social care costs may be incurred, but we do expect to see efficiencies emerge.8 Relationships The Programme requires cross government and public sector wide collaboration to ensure successful design, delivery and implementation of health and social care reform through the National Care Service. The agreement on shared accountability between Scottish Ministers, Local Authorities and the NHS will require the creation of new governance structures that should not introduce risk to existing planning mechanisms or delivery responsibilities and instead will enhance and clarify relationships. Technology New technology will be required to deliver the integrated social care and health and social care record. Our developing evidence base also indicates a mixed picture of digital maturity in the social care sector and a resultant need to invest in the sector to improve digital capacity and capability to successfully implement the required technology. This poses technology risks in terms of successfully developing the technology; ensuring any technology is sufficiently safe and secure for personal and special category data; and ensuring successful deployment of said technologies into the sector. There is significant work already underway to ensure the NHS has the capability and capacity to support the introduction of the record.
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Maintaining existing services The existing health and social care system is already stressed. Safely landing additional change in that environment will be challenging. Careful planning and prioritisation of the phases of change will be required in mitigation. Changes to the existing system must not result in a reduction of service quality or introduce additional risk to the services experienced by individuals. 1.4 Economic Case The Economic Case outlines the expected benefits for people using care services, working in care services and the way in which the NCS will enable the Scottish Government to implement broader government objectives with maximum impact. Dependent on the final form that the NCS takes, there is potential for substantial benefits to be realised from the NCS, and the associated wider social care reform committed to by the Scottish Government. This Economic Case explores what these could be and provides a framework for future detailed quantification of benefits as the programme develops. 1.5 Finance Case (See shared accountability paper) The costing of the Programme is included in the accompanying shared accountability paper. 1.6 Management Case The management case sets out in Section 6 the Programme management approach to support successful delivery as well as the Programmes management and control approach. Scottish Government, Director General of Health and Social Care (Accountable Owner) and Senior Responsible Officer (SRO), the Director of the Social Care NCS Development Directorate lead the Programme. The cross-cutting nature of the Programme requires collaborative working across the Scottish Government and the wider social care sector to develop policy, design, and implement an NCS that brings together community health and social care to deliver change and benefits safely. A Programme structure has been developed, which sets out the Programme hierarchy, phasing, and underpinning projects.
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9 National Performance Framework 2. Strategic Case 2.1 Introduction The purpose of the strategic case is to make the case for change and demonstrate how the programme provides strategic fit with Scottish Government’s national outcomes as outlined in the National Performance Framework. The case also sets out the policy context, available evidence and information that supports a compelling case for change and alignment with the broader strategic direction including interdependencies, constraints and risks for the work proposed. 2.2 The strategic context for a NCS Programme 2.2.1 Scottish Government aims and strategies. The National Performance Framework (NPF9) defines the purpose of the wider public sector as “to focus on creating a more successful country, with opportunities for all of Scotland to flourish, through sustainable and inclusive growth.” This purpose is underpinned by the values that Scotland is “a society which treats people with kindness, dignity and compassion; respects the rules of law; and acts in an open and transparent way.” The delivery of integrated community health, social work and social care services that best support people has been at the heart of Scottish Government policy since devolution. The proposed investment in and reform of integrated community health, social work and social care services will touch all the key areas of the National Performance Framework by: 2.2.2 Relevant Strategies The delivery of an NCS builds on the work of the Scottish Government to date including: The Public Bodies Act (2014) which established Integration Authorities. The work conducted under the Adult Social Care reform programme from 2019. The Adult Social Care Statement of Intent in March 2021 in which Scottish Government and Convention of Scottish Local Authorities (COSLA) agreed to work together on the key foundational aspects of the Independent Report on Adult Social Care. The actions underway as part of the Proactive and Preventative Care Programme, Fair Work action plan, as well as rollout of Housing First Scotland. Wider strategic plans and approaches including The Promise, Digital Health, and Care Strategy (2021) and A Changing Nation: How Scotland will thrive in a digital world (2021); and Creating a more successful country. Giving opportunities to all people living in Scotland. Increasing the wellbeing of people living in Scotland. Creating sustainable and inclusive growth; and Reducing inequalities and gives equal importance to economic, environmental, and social progress.
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11 Verity House Agreement The 2019 Primary Care Outcomes Framework. The Scottish Approach to Service Design10 These strategies provide the context for a shift in how health and care is delivered in Scotland, to place people, human rights, and equality at the heart of decision-making, and build together a future system that enables consistency, quality, and fairness at the core. The Scottish Government is undertaking multiple large scale reform programmes: Keeping the Promise Implementation Plan Tackling Child Poverty Delivery Plan 2022 - 26 The National Strategy for Economic Transformation The Climate Change Plan The Care and Wellbeing Portfolio Public Sector Reform Getting it Right for Everyone In addition to the above large-scale programmes the NCS will be delivering in line with the Verity House Agreement signed in June 2023.11 The agreement is a partnership agreement between the Convention of Scottish Local Authorities (COSLA) and the Scottish Government “setting out our vision for a more collaborative approach to delivering our shared priorities for the people of Scotland”. In line with the Verity House Agreement the NCS Programme has reached agreement that the NCS will operate with shared accountability between Scottish Ministers, Local Authorities, and the NHS for the oversight and delivery of integrated health and social care. 2.3 The case for change 2.3.1 The current system This section sets out the current system in Scotland that delivers care and support to the people of Scotland. It provides additional context for the case for change. Currently social care support across Scotland is delivered by a wide range of partners, including organisations in the public, private and third sectors. Social care is provided in people's homes, including through remote care and technology-enabled care, in residential accommodation and care homes, or the wider community, including many advice and support services. Currently, local authorities are responsible for social work and social care support, and local health boards are responsible for health services. They work together as integration authorities to assess the needs of their area and plan and commission local community-based health and social care services, using funding contributed by the local authority and health board. Health boards and local authorities in each local area are responsible for delivering local community-based health and social care services as directed by the integration authority, including adult social work and adult social care support, community health services for adults. Some integration authorities also 10 The Scottish Approach to Service Design (SAtSD)
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have responsibility for children's health, children and families social work and social care, justice social work, and homelessness and housing support. To foster an integrated approach to delivery of support services, the public bodies in each area bring their workforce together under what is known as Health and Social Care Partnerships (HSCPs). Community health, social work and social care is there for people of any age who need assistance with day-to-day living due to illness, physical disability, learning disabilities, mental health conditions or issues relating to older age, frailty, or dementia. There are three functional areas of social work and social care in Scotland: adult, justice and children and families. 1. Adults – Adults’ social work and social care services provide assessment, support, and interventions to people aged 18 or over who may need additional support due to physical illnesses, physical or learning disabilities, mental health conditions or general frailty. 2. Children - Children’s social work and social care services provide assessment, support and interventions for children and families, or where children are unable to live with their own families. 3. Justice - Justice social work and social care services provides assessment, support, and interventions for people in relation to offending or alleged offending, including though diversion from prosecution, bail supervision, delivery of community orders, and supervision and support for those serving prison sentences before and after release. 2.3.2 Scale of demand on the current system The population receiving community health, social work and social care support is diverse, with wide ranging needs and circumstances. In many cases, the needs and circumstances of individuals mean they may interact with other services, including those relating to education, housing, social security, and justice, provided by both the public sector and others including voluntary and third sector bodies. Some of these needs are met by unpaid carers who support their families and loved ones, with an estimated 700,000-800,000 people providing this kind of support12. The latest data (2019/20-2020/21) for the population receiving community health social care and support is summarised below13: Social Care: 17% of the adult population (over 16) provide care to one or more person. Around 1 in 25 people in Scotland were reported as receiving social care support and services at some point in 2021/22 Around 65,500 people in Scotland are receiving home care at any one point. The proportion of people receiving social care through any self-directed support option increased from 18.4% (2020/21) to 18.9% (2021/22). The percentage measure is based on the number per 1,000 population of those receiving self-directed support vs. the number of people per 1,000 population receiving social care by any means. 12 Scotland’s Carers: Update Release 12 April 2022 https://www.gov.scot/publications/scotlands-carers-update-release-2/ 13 Insights in social care: statistics for Scotland - Support provided or funded by health and social care partnerships in Scotland 2021/22 - Insights in social care: statistics for Scotland - Publications - Public Health Scotland#
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Around 33,000 people received funding towards a long stay care home place in Scotland during 2021/22. A high proportion (43%) of people accessing social care support are elderly and/or frail. Almost 1 in 3 (32%) have a physical or sensory disability. Around 6% are receiving social care support due to mental health issues. There were an estimated 32,800 long stay residents aged 18 years and over in Care homes on 31 March 2023, 6% fewer than 31 March 2013. Care homes for older people (65 and over) accounted for 92% of long stay residents in all care homes for adults, with around 63% of older residents with dementia.14 People can be receiving support for more than one reason, for example: problematic substance use, neurological conditions, dementia, palliative care, autism, or other vulnerabilities. Based on the Local Finance Return (LFR), the cost of social care in 2021-22 was £8.2 billion.15 Primary Care16: As of 1 July 2023, there were around 5.9 million patients registered with General Practices in Scotland, an increase of 2.1% over the past two years.17 The number of patients aged 65+ has increased by 20% since 2012.18 The total number of General Practices in Scotland is falling, and the average practice list size is increasing. The average practice list size in Scotland for 2022 was 6,470 patients. 19 Mental Health In 2021/2022, people living in the most deprived areas were around three times more likely to experience inpatient mental health care than people living in the least deprived areas20. Of the patients who experienced mental health inpatient care in 2021/2022, 53% were male21. However, in the under-18 age category, 73% of patients were female22. 14 Dashboard - Care home census for adults in Scotland - Statistics for 2013 – 2023 - Care home census for adults in Scotland - Publications - Public Health Scotland 15 Scottish local government finance statistics (SLGFS) 2021-22: workbooks - gov.scot (www.gov.scot) 16 Definition: Primary care is the first point of contact with the NHS. This includes contact with community-based services provided by general practitioners (GPs), community nurses, dentists, dental nurses, optometrists, dispensing opticians, community pharmacy and general practice-based pharmacists and pharmacy technicians. It can also be with allied health professionals such as physiotherapists and occupational therapists, midwives, and pharmacists. Primary Care also encompasses urgent community care including out of hours service provision. 17 General practice - demographics data visualisation - Up to 1 July 2023 - General practice - demographics data visualisation - Publications - Public Health Scotland Note that the total number of patients registered is higher than the latest Scottish population estimate; PHS are working with NRS to understand the reasons for this difference. 18 General Practice - GP Workforce and practice list sizes 2012 - 2022 - General Practice - GP workforce and practice list sizes - Publications - Public Health Scotland 19 General Practice - GP Workforce and practice list sizes 2012 - 2022 - General Practice - GP workforce and practice list sizes - Publications - Public Health Scotland 20 Data summary - Mental health inpatient activity - 28 March 2023 - Mental health inpatient activity - Publications - Public Health Scotland 21 Data summary - Mental health inpatient activity - 28 March 2023 - Mental health inpatient activity - Publications - Public Health Scotland 22 Data explorer - Mental health inpatient activity - 28 March 2023 - Mental health inpatient activity - Publications - Public Health Scotland
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Justice Social Work23: There were around 17,600 social work orders commenced in 2019-20, which was 15% lower than the peak in 2016-17. In 2020-21 and 2021-22, this was 8,500 and 12,600, respectively. These figures are lower than previously reported because of the COVID-19 pandemic. There were 16,800 community payback orders commenced in 2019-20, a rise of two per cent on the year prior. These were lower than 2019-20 during the pandemic years: 8,200 in 2020-21 and 12,200 in 2021-22. There was 1,900 statutory custody and community based through care cases commenced in 2019-20. These were lower than 2019-20 during the pandemic years: 1,500 in 2020-21 and 1,700 in 2021-22. The number of drug treatment and testing orders commenced was 520 in 2019-20. These were lower than 2019-20 during the pandemic years: 230 in 2020-21 and 360 in 2021-22. Young people aged 16 to 20 represent 7% of the Scottish population aged 16 to 70 in 2020- 21 and accounted for 9% of criminal justice social work reports submitted and community payback orders imposed and 20% of fiscal work orders imposed. Children’s Services24: On 31 July 2022, 12,596 children were being looked after in Scotland. This includes those looked after at home, with kinship carers, with foster carers, in other community settings, or in residential accommodation. On 31 July 2022, 2,031 children were on the Child Protection Register. On 31 July 2022, 382 children were both looked after and on the Child Protection Register. On 31 July 2022, the rate of children (0-15 years) on the Child Protection Register varied considerably by local authority, ranging from 0.5 per 1,000 children in East Renfrewshire to 4.2 per 1,000 children in North Ayrshire.25 During 2020/21, around 3,000 children and young people aged 0-17 received social care services or support in Scotland, of which 22% had a learning disability and 16% a physical and sensory disability. 515 children and young people had community alarms or received telecare support, 195 home care and 70 children and young people were in a care home.26 5,230 children and young people started treatment at Child and Adolescent Mental Health Services (CAMHS) in Scotland during the quarter ending June 2022. Of these, 68.4% were seen within 18 weeks, compared to the standard of at least 90% of children and young people to receive treatment within 18 weeks of referral.27 23 Justice Social work statistics 2021-22 24 Children’s services include children’s community health, social work, and social care services. 25 Children’s Social Work Statistics Scotland 2021-22 26 Insights in social care: Statistics for Scotland 27 Scottish Government Performance against LDP standards
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2.3.3 Reform of Health and Social Care in Scotland up until this point The figures above show that the demand and investment on Health and Social Care is significant and far reaching. There have been initiatives to reform the system previously. Figure 1 sets out the published reports which preceded IRASC, and how reform was considered and initiated.
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Figure 1: Published Reports on Health and Social Care Reform
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The introduction of the 2014 Public Bodies (Joint Working) Act was intended to address the challenges present in the community health, social work, and social care system at the time. The published documents set out in the above diagram provide a narrative on that implementation. The key learning points and areas to consider based upon the experiences to date of implementing health and social care integration are summarised below. Table 2: Initial focus on entity rather than service or service user The requirement to have the Integration Authorities (IA) in place by a set deadline meant much of the focus was on leadership and structures. There was not enough focus on how services would be delivered differently. There was little room for trial and error, building on what works or for designing the service and wider features around the user. The start – and end – was to set up the IA. The IA has limited authority to change. Other than NHS Highland, the structures of IAs mean that the IA is intended to be the strategic commissioner and has statutory responsibility for decision-making, but the delivery bodies retained statutory delivery responsibility. The IA therefore has limited ability to change the profile of delivery, to innovate or redirect resources. Funding made it hard to remove the ‘organisational’ lens. IAs represented a limited change to the existing funding model - funds were ceded to IAs and then largely given back to the hosts from which they came. There was little risk sharing or ability to invest in one area to save in another. This impairs the policy intent to invest more in prevention and pro-active care, as funds released from acute services that see reduced costs are often reinvested to meet the growing demand for acute services (as investment is not otherwise available to meet this demand). One review concluded that this means that funding needs to be ‘new’ rather than abstracted from the acute services which would see reduced costs. Distinct entities behaving differently. The culture, professions and system for Community Health, Social Work and Social Care delivery are different. Where there is increased integration in the form of ‘lead agencies’ or recently through the Enhanced Professional and Clinical Oversight, the view tends to be that the clinical/medical approach becomes dominant rather than a true integration of approaches. Over-reliance on leadership The system for IAs placed high reliance on strategy, commissioning, and governance. To do this the IAs only have to produce three documents – an annual performance statement, a strategic plan (every three years) and an annual finance statement. IJBs were required to have several representative groups on the Board. The high turnover of Chief Officers, over-reliance on a few key leaders within the system and a limited number of Board meetings for the significance of the work in hand did not provide the required drive for change at a local level. For example, the ability to focus efforts on changing how third parties are commissioned and engaging them differently on a relationship basis was highlighted as
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taking time, energy, and consistency of leadership, as well as needing changes to ways of working beyond the leadership team layer itself. 2.3.4 Good Practice within the Current System Although quality of provision across Scotland is not consistent, within the current system, there are examples of social care being delivered to a high standard, despite the scale of the challenges faced by the sector. Some examples are below. The Independent Review of Adult Social Care (published in February 2021) heard many examples of good practice in the current social care system, and noted “the dedication and responsiveness of people in the workforce”, how “self-directed support [is] enabling people to ‘live a real life’”, that integrated health and social care support services are “jointly focusing on the wellbeing of the person using care”; and also recognised the support being given to carers in order that they can carry on caring for their loved ones. The review found that Integration Joint Boards “have had benefits in terms of health and social care support services working together better locally” and that the social care workforce is 'motivated', 'resilient', 'adaptable' and 'proud of their work'. Good examples were also noted about engagement with the Care Inspectorate, including observations like “inspections being based on dialogue and improvement.” 2.3.5 Conclusions on Scale of Demand on the Current System Ensuring that the health and social care system is prepared to deal with the changing needs of the people of Scotland is an important element for the general wellbeing of the country. The system must have an increasing level of resilience that is able to deal with a variety of ongoing challenges and pressures. The Scottish Government is committed to supporting the delivery of Social Care services within Scotland. Through dedicated funding to local bodies, provision should be made at a local level that is responsive to the needs of local communities. The Scottish Government in collaboration with partners has an important role in driving improvement and collaboration across the country as well as coordinating response to emerging issues and pressures. The Granite Care Consortium (GCC) was commissioned by Aberdeen City Health and Social Care Partnership to deliver Care at Home services from 1st November 2020. GCC consists of 10 care and support providers, all of whom are experienced in delivering care in the city. The focus of the new model moves away from tradition time and task model to one that is more responsive to delivering individual outcomes. There will be an increased focus on local assets to connect people back into their communities. The model also aims to improve market stability and provide greater stability for the workforce. The model allows the packages of care to be stepped up and stepped down in response to changing needs and in close collaboration with service users, their families and those directly involved in providing the care. An evaluation of first year of operations was carried out by Coalition of Care and Support Providers Scotland (CCPS) and formed part of GCC’s Annual Report 2020-21.
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The health and social care system is still recovering from the Covid Pandemic as well as responding to other emerging issues such as a changing demography and workforce pressures. These issues present the system with challenges that require a holistic approach to ensuring that it remains able to deliver for the people of Scotland. The economic case provides additional detail, in summary the system is failing to meet current demand and significant reform is required to enable it to meet future demand in terms of Scotland’s future needs, including the projected burden of disease and the ageing population. Moreover, IRASC identified that many current costs in Social Care are driven by crisis management and late interventions, for example people who are delayed in hospital. It is estimated that delayed discharges cost the system £134 million a year, plus the wellbeing loss experienced by individuals.28 Eliminating or reducing this cost to the acute health service is not necessarily a reduction in cost to the public purse. Instead community health and social care costs may be incurred, but we do expect to see efficiencies emerge. 2.3.6 Problem Statements The IRASC highlighted the challenges with the current system through a series of problem statements, primarily focused on Adult Social Care. These have been built on further throughout the business case process as follows: • Reviewing other policies, research, reports, and analysis on the services in scope – including The Promise. • Holding working sessions with those with lived and living experience of the community health and care sector and understanding their journey through the current system. Through this wider work a longlist of over 200 problem statements were developed that cover issues across the community health and social care system. These have been summarised and grouped together into nine themes. These problem statements highlight the need for a ‘whole system’ response. The issues identified are not solvable through one off measures or by individual reforms. As the initial view of potential enablers shows, they point to a scale of reform which is comprehensive, addresses the fragmentation of the current system, and can overcome the barriers that have prevented the current ways of working from making these changes. They also reflect messages that have been repeated in previous years and which have not resulted in the level or pace of change needed to address them. 28 Independent Review of Adult Social Care (2021) (link)
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Figure 1: Problem Statements. Person-centered rights-based care The current system is often not designed with the individual’s needs at the forefront, nor is it coordinated or flexible enough to reflect and address the changing needs of individuals. It requires people to re-tell their story within and across different parts of the system creating frustration and trauma for them, and inefficiencies for the system. As a result, many people and families feel support is hard to access and is system rather than person-centred. People who use care and their families often describe the social care system as over complicated. This is largely driven by the current processes surrounding support planning which are not streamlined – making the system difficult to navigate and hindering people’s ability to access social care support in a timely manner. The aim of personalisation, for example through Self Directed Support (SDS)is not being met to a sufficiently high level. The HACE survey previously referenced showed around 1 in 4 people who receive care did not feel they had a say in how it was delivered. The existing eligibility criteria were cited within the IRASC as acting as barriers to accessing support, and often failing to acknowledge and support the whole needs for a person. The creation of Integration Authorities and the Health and Social Care Partnerships which deliver services was intended to provide a more co-ordinated and person-centred approach. While it is recognised integration authorities have made improvements in some areas – IRASC, the Audit Scotland review of Health and Social Care Integration and the Ministerial Working group on Health and Social Care Integration progress review have found they have not made sufficient progress. Prevention not Crisis The current system often focuses on acute crisis support and there is a lack of access to the preventative care and early intervention needed by people to support them to live an independent and fulfilling life and reduce the future need for high-cost crisis support. This cycle leads to people feeling that the system is failing to meet their needs and leads to increased use of other health emergency/ acute services which results in further inefficiencies in the system such as delayed discharges. The difference in the operational style and context of NHS and Local Authority organisations reinforces different behaviours, with Social Care/Local Authority services often seen as the ‘poor relation’ due to an inability to shift funding and attention from acute care to more preventative and pro- active interventions.
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Stakeholders, representing people who access services, providers, and those within the current system, raised the issue of short-term funding preventing long term planning and capacity to invest into preventative support services. Eligibility criteria create barriers to accessing services, meaning people are unable to access the most appropriate support at the right time. Individuals and Unpaid Carers Currently the complex bureaucracy within the system too often excludes the individuals in receipt of care and support, their families and unpaid carers from assessment and support processes. This needs to be balanced with a stronger advocacy system that protects vulnerable people while supporting families to be involved in a meaningful manner. For unpaid carers particularly there remains concern about the consistency of access to information about the support available and the complex and lengthy processes required to get appropriate support for opportunities to step away to undertake everyday tasks, recharge and take a break. Evidence from Carers Scotland reveals almost three quarters (72%) said they had to continue providing care even though they felt they were at breaking point.i Unpaid carers faced an extraordinarily challenging time providing many more hours of unpaid care during the pandemic, with reduced support available from health and social care services and limited help from their support networks. Research shows that just over a third of carers (35%) in State of Caring 2023 had not had any break from caring in the past year, often saying that it is just too difficult to get the breaks they desperately need.ii IRASC findings and feedback from Current Operating Model (COM) workshop attendees showed that there is a need for improved and more consistent support for unpaid carers to carry out their caring role and to take a break from caring, with regular access to a range of options for respite. Workforce The lack of parity between third, independent, NHS and local authority staff, with variation in remuneration, training and an unclear career pathway all contribute to the perception that caring is not an attractive career, leading to recruitment and retention issues. Other cultural factors and perceived hierarchies that exist within the workforce can result in individuals in receipt of care and support not placing equal value across all professions involved with them. For example, even before the current challenges with cost of living, carers were more likely to be in poverty than people without a caring role. According to the Joseph Rowntree Foundation, 44% of working age adults who are providing unpaid care for more than 35 hours a week are in poverty.iii Job market competition from other sectors with more attractive T&Cs (e.g. retail, hospitality) is also impacting recruitment and retention. Currently there is not a unified approach to learning and development. Areas of development include the need to establish clear career pathways and to identify the skills that workers need to develop, including leadership development and retention. There is no financial incentive for career
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progression due to the erosion of pay differentials with added responsibility. Training is the responsibility of employers, but funding options are complex with little oversight on the quality of training. At present, social work education, continuous professional development and improvement are supported and provided by several organisations and agencies, including local authorities and the Scottish Social Services Council (SSSC). The Scottish Government sets the overall strategic framework for the delivery of social work and has oversight of some of these bodies, namely the SSSC. There is no single national body tasked with having oversight and leading social workers’ professional development, education, and improvement. Terms and conditions of social workers employment are set by individual employers, resulting in local variations in social workers’ pay and grading. Consistency and Quality There is a lack of consistency and a variation of quality of provision and services across Scotland. This can be attributed to a number of factors including interpretation of eligibility criteria regulations; interpretation and/or implementation of the Self-Directed Support Act; the extent of choice of provider or service available locally; and the variation of Integration Authority remits across the country and regulations and scrutiny that too often focus on procedure and process rather than on individuals’ experiences of care. People have stated that these factors along with the lack of a clear improvement framework for social care led to a feeling of a postcode lottery. For example, looking at SDS, according to the National Report on ‘My Support My Choice: People’s Experiences of Self-directed Support and Social Care in Scotland (Oct 2020)’, there has been difficulty in contacting social work departments, particularly when trying to obtain information about how to access SDS (Self Directed Support) for the first time. Variable information was reportedly given to service users about the four SDS options that links into people's needs assessment. While it is generally clear how to make a complaint in relation to SDS and despite the positive outcomes that are achieved through a complaint, it is noted that the actual process itself can be inconsistent, unpredictable, and dependent on various factors, such as geographic location, the person receiving the complaint and levels of individual awareness.
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System Intelligence and Governance The community health and social care system is seen as complex, with little transparency. Having multiple public sector bodies with different governance and accountability structures makes creating the conditions for collaborative public sector and provider relationships challenging. This impacts on the ability to fulfil tasks such as joint planning, risk sharing and providing oversight. The system is difficult for people to navigate with multiple interfaces that leave them unclear about where responsibility and accountability for their care and support rests. Integration Authorities were introduced to integrate Local Government and Health services, but it has proven hard to make this work in practice. Some of the key issues include the following: There has been high leadership turnover due to many issues. For example, the challenge of working in a complex governance environment and the need for IJB members to act in the interest of the IJB but also hold their substantive posts. The intention of integration was to pool resources and then direct them according to a shared plan, based on needs. In practice much of the funding appears to be ‘circular,’ with funding allocated to the IJB from the local authority and health board, which then directs it back to the local authorities and health boards (and Health and Social Care Partnerships) to deliver. The scale of funding of the IJB relies on the financial position of its partners. The financial planning and budget cycles are not aligned; Local Authorities must agree budgets and set council tax by the end of March while NHS Territorial Boards work to different timescales. Therefore, statutory bodies apply different budget setting timescales with IJB’s’ budgets being set last, making joined up planning for resources harder. Regulation and Standards There is a disconnect between the considerable number of different standards in social care, the priority attached to these and awareness of them by those who are delivering and receiving services on the ground, creating an implementation gap between policy and practice. The handling of complaints and problems is also made more difficult as there is no single standard/measure. The current system regulates individual providers, tackling underperformance highlighted through inspection with no embedded sectoral improvement strategy. There is a view that social care roles are poorly defined across local authorities, third sector and independent providers and the NHS. A lack of understanding on the range of roles and responsibilities including a clear distinction between social care and social work (whilst also recognising its inherent partnership) has been raised with a need for the workforce to have its own “professional identity.”
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Further issues have been highlighted with current commissioning and procurement practices which are seen to be characterised by mistrust, conflict, and market forces, with procurement practices in social care increasingly driving and sometimes undermining strategic commissioning and planning decisions. The lack of autonomy at different levels over-complicates the system and restricts decision-making. Continuous improvement There are multiple organisations with the remit and role to support improvement. However, as set out throughout this analysis, a fragmented system makes it harder to trace improvements through to either individual or national outcomes and therefore risks improving process and activity rather than driving better results. There are also barriers in addressing known performance issues among some providers because of the limits of the regulatory powers available. It is recognised that a lack of collaborative leadership and lack of strategic capacity has affected the progress of integration in some areas. Integration remains poorly understood and workforce pressures are a clear barrier to the implementation of integration plans. 1 State of Caring 2023: A health and social care crisis for unpaid carers in Scotland, November 2023. Carers Scotland 1 State of Caring 2023: A health and social care crisis for unpaid carers in Scotland, November 2023. Carers Scotland 1 Joseph Rowntree Foundation. Poverty in the UK 2022.
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2.3.7 Summary of the current case for the NCS There has been unprecedented demand on the Scottish health and social care system in a time of global challenge and uncertainty. Meeting demand will only become more challenging in the future with an ageing population with more complex needs. To deliver a system which meets Scottish Government ambitions, in terms of outcomes and services for the people of Scotland, it is essential to consider fundamental and systemic change, that optimises the system and makes real change for people. The Public Bodies Act is not delivering the embedded approach to integration it was intended to, meaning that many people are failing to have their social care needs met. The Independent Review of Adult Social Care (IRASC) was instrumental in identifying how these fundamental changes might be implemented. The Programme recognise that any solution envisaged for social care must address the IRASC problem statements. There are significant workforce issues within the current Social Care system (also identified by IRASC). The NCS must seek to address these throughout the entirety of the Programme lifecycle and beyond. Specific key issues include challenges around staff recruitment and retention. Cultural paradigms and leadership issues are also suggested as key issues requiring consideration. In 2021/22, there were 236,000 people in Scotland reportedly receiving social care support or services.29 If it is assumed that 10% of this group (23,600 people) experience a 0.1 point improvement in wellbeing because of the establishment of the NCS for the reasons discussed above, then this could lead to a potential annual benefit of around £34 million (2021 prices). In 2021, there were around 130,000 people employed in the Adult Social care sector.30 If it is assumed 10% of this group (13,000 carers) experience a 0.1 point improvement in their wellbeing on the life satisfaction scale because of the establishment of the NCS, then this could lead to a potential annual benefit of around £19 million (2021 prices). 2.4 Scope of the Programme The National Care Service (Scotland) Bill was published in June 2022; and has legislated for the maximalist approach to scope for inclusion within the NCS, which includes Children and Families services, Justice Social Work and Community Health Services along with Adult Social Work and Social Care Services. At the time of Introduction this included the transfer of full accountability, functions, staff, and assets to Scottish Ministers and included the set-up of local care boards to replace Integration Authorities. This option has been refined further following ongoing definition and evidence gathering as well as alignment with the recent Verity House agreement with Local Government The Scottish Government has reached an initial agreement with local government and the NHS about shared accountability arrangements for the National Care Service (NCS). Overall legal accountability will be shared between Scottish Government, the NHS and local government. Staff will continue to be employed by local authorities, which will also retain assets and delivery 29 People supported - Insights in social care: statistics for Scotland - Support provided or funded by health and social care partnerships in Scotland 2021/22 - Insights in social care: statistics for Scotland - Publications - Public Health Scotland 30 This only includes those working in adult day care, adult placement services and housing support/care at home. It does not consider health workers: Scottish Social Services Council, August 2023 (link)
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functions with similar arrangements for all NHS Health Boards assets, staff, functions, and contracts. New governance arrangements will be introduced. These will be introduced to ensure consistently high levels of service across the country, while building the flexibility to meet varying community needs at a local level. Agreement has been reached that a National Board will be established to oversee these new governance arrangements, with the detail and functions to be designed in collaboration with key stakeholders and those who access and work in the sector. In addition, ongoing collaborative work will support the development of the preferred options for local reform, rather than the creation of Care Boards. Figure 2: NCS Programme High level visual The figure below provides a visual representation of the scope of the NCS Programme that takes account of these recent agreements.
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PBC Children’s services The IRASC concluded that "for Scotland to truly be the best place in the world for children to grow up, a fundamental shift is required in how decisions are made about children and families.” For this fundamental shift to happen, services must be designed in a truly collaborative way. The Scottish Government is committed to delivering The Promise in partnership with the wider children’s services sector. Further consideration is required as to whether the integration of children’s social services with adult and community health services in the NCS could provide a structure and system in which The Promise can be delivered and maintained more effectively than out with the NCS. The NCS model could improve these services for disabled children and children with health issues and improve transitional arrangements as young people reach adulthood. Strategic aims for delivering The Promise and making improvements in children’s services have been identified, which could be achieved by locating these services in the NCS. Including children’s services in the scope of the NCS may be an opportunity to: address variation in access to and quality of services move to a more consistent national approach. set standards of care and strategic planning reduce variation in thresholds for services. improve accountability and shift focus to early intervention. improve alignment with community health services. improve transitions between children’s and adult services. Justice Social Work Services Justice Social Work Services differ to other parts of the social care sector in that they tend to be court imposed (and so are largely non-voluntary); have limited scope for the affected individual to influence service delivery; can be partly aimed at the punishment of those who have committed an offence in addition to rehabilitation and support; and have a focus on public protection and the management of risk. These aspects will all be taken into account when considering how justice social work services may be incorporated into the NCS (and what implications that may have for the wider model of Community Justice), in close discussion with relevant stakeholders. Community Health Services We recognise that there are still a number of decisions to be made with regard to the scope of this business case for community health, and that work to capture further detail and key issues in Community Health more widely will continue for the next iteration. In relation to Community Health services for children, further consideration is required regarding the inclusion of Children’s Services within the NCS. Under the current Health and Social Care integration arrangements we have services that must be delegated at a minimum and others such as Mental Health and Neurodiversity services that are optional. This means there is currently much variation across Scotland. Delegation of prescribed functions has not been consistent across the country, and this is leading to confusion and a lack of clear accountability. Areas which have delegated a number of functions have demonstrated the potential of integration and we therefore must now assess how best to advance delegation of services under the NCS further.
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PBC 2.4.1 NCS programme scope of delivery 1. A National Board to oversee shared accountability. The NCS National Board will ensure consistent, fair, human rights-based Social Care support and Community Health services, underpinned by effective complaints and advocacy for people. At the same time, it will support communities to maximise the benefits of reformed local delivery of services. The NCS National Board will drive forward improvements across the system by supporting collaborative leadership and greater collaboration between partners. It will also seek to improve the quality and consistency of services and ensure services are sustainable and person-led by undertaking new functions at the national level that are not in place in the current system. The Board will be accountable for standards, guidance, and performance metrics, with an agreed support and improvement framework which will aim to help local areas when monitoring indicates that standards are not being met. The functions of the Board will be finalised through further work and co-design; however, at a high- level agreement on the following functions has been reached: o setting national strategic direction. o developing standards, guidance, and operating frameworks. o overseeing and seeking delivery assurance on local strategic plans and ethical commissioning strategies. o monitoring system performance. o maintaining a support and improvement framework which will aim to provide support to local areas when monitoring indicates that standards are not being met with powers of intervention, when required, as a last resort. o ensuring visibility of data, information, and analysis about social care support, social work, and primary and community health services through reporting on delivery. o national commissioning and procurement by agreement for complex and specialist social care services which will include prison social care. o seeking assurance on public protection arrangements; and o providing support to local delivery partners. When it is established, the National Board will need to be supported to fulfil its functions. The intention is for the National Board to enhance capacity in the system, and this needs to be reflected in the way it is resourced. Further work is needed to determine the best way to support the National Board and what its status should be. Our planning assumption is that, when the Board is established, the Scottish Government’s work on policy, delivery and improvement activity relating to the services in scope for the NCS will continue and will be aligned to the work of the Board. An assessment of the options for delivery, value and costs will be made through the development of an outline business case on the development of the NCS National Board. 2. National Social Work Agency The National Social Work Agency will provide a single national body with oversight of social work education, training and professional development, and the improvement of social work services. Its objectives will be to support and invest in the social work profession by providing national leadership and overseeing social work education (pre/post-qualifying), improvement, workforce planning, training, development, and implementation.
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PBC It will work collectively with partners to address workforce pressures and factors impacting on supply and the recruitment and retention of the social work workforce. The Agency will be located within the Scottish Government but will be a partnership which works with key external stakeholders and employers to support local solutions, develop regional approaches where appropriate and where needed, national approaches. It will be an opportunity to address some of the longstanding issues impacting on the sector and will seek to improve consistency in service delivery and crucially, enable social workers to work more effectively to transform people’s lives and implement rights-based practice. 3. Develop national functions. There will be an ongoing need for Scottish Government to support Scottish Ministers. The Programme will manage an organisational change project that will support integration by ensuring policy development and improvement is delivered to support the aims and objectives of the NCS. This will promote and foster more joined up person-led collaboration at local level between different parts of the Health and Social Care system and other related services through effective integration with the NHS at national level and effective joined up working across the public sector at national level. Options for this will be determined through the Programme’s definition phase and will promote integration and Getting it Right for Everyone (GIRFE) principles and embed Human Rights in policy making and delivery across all areas of the NCS. Working to support the National Board in policy development and improvement, ahead of the introduction of the National Board, the National team will continue to support policy development and improvement, identifying and delivering early improvements ahead of the introduction of the National Board. For the most part this will be a realignment of existing Scottish Government policy teams to support joined up and integrated policy making in line with GIRFE principles. There will be a need for some additional investment in some NCS National workstreams. These will include the development of a complaints service and a consistent approach to independent advocacy, building on services currently provided and filling gaps in provision where identified. Where that is the case, the workstream will be supported by the development of specific business cases, that will outline, costs, benefits, and value for money of proposed options for delivery. 4. Transform local delivery through Reformed Integration Authorities The shared accountability agreement between national and local government included agreement that statutory delivery functions would remain with local government and health boards respectively, along with assets, employment, and relevant funding. Consequentially, there are provisions in the NCS Bill as introduced which would no longer be intended to be used as originally envisaged. The Programme has therefore been examining whether the intended outcomes could be achieved by putting forward amendments to the Public Bodies (Joint Working) (Scotland) Act 2014 under which the integration authorities were created. We are now of the view that this is a reasonable approach and would achieve the intended reforms in a manner proportionate to the aim. There continues to be a need for reform, with significant changes needed at local level to realise the intended quality and consistency.
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PBC To ensure that there is a clear link between local and national shared accountability, the programme will ensure through this project that processes are in place for reformed integration authorities to be accountable to the National Care Service Board, with the National Care Service Board responsible for reviewing, and securing assurance on the deliverability of local strategic plans. Under this continuous improvement approach it is intended to carry over any existing powers under the 2014 Act which have not yet been used in practice, such as the powers to allow integration authorities to directly employ chief officers and other members of staff. We will also strengthen the opportunities for Integration Authorities to join together across current geographical boundaries to achieve greater consistency, quality and economies of scale where there is local agreement to do so. It is also the intention that the role of localities should be strengthened, building on what works well and driving greater consistency in how these are set up and used as part of community engagement, strategic planning, and other integrated functions. Finally, it remains the Scottish Government’s intention that the recommendation to give a greater voice to lived experience within decision making structures should be actioned, including by extending who on the board has voting rights. Local reform will be delivered in alignment with the Verity House agreement and the Programme’s commitment to co-design. This will support the ambition to create a comprehensive Community Health and Social Care service overseen by a National Board that supports individuals and smooths transitions between different categories of care based upon local needs. Detailed scope, benefits, value, and costs for the preferred approach to local reform will be presented as part of a local reform business case. 5. Integrated Social Care and Health Record (IHSCR) The Independent Review of Adult Social Care highlighted the frustration that many people felt of being “asked to repeat the same information to several different professionals when better data sharing arrangements would remove the need.” It highlighted how technology in general can “help with people’s ownership of their care and support, particularly when people “own” their own data or information that is about them and share it with the people who support.” To in part address this, the Scottish Government consulted on the idea of ‘a nationally-consistent, integrated and accessible electronic social care and health record’ in the Using Data to Support Care’ section in the formal public consultation for NCS on. Notably, 85% of individuals and 89% of organisations taking part in the consultation agreed to this proposal, supporting the idea that information about their health and care needs should be shared across health and social care services. Moreover, there was a strong view that care services should be more focused on individual needs and with individuals having more access over their care and information. The commitment to improving information sharing and access to information is long-standing: in 2018, the Scottish Government and COSLA committed to deliver “a Scottish health and care 'national digital platform' through which relevant real-time data and information from health and care records, and the tools and services they use, is available to those who need it, when they need, wherever they are, in a secure and safe way.” This followed a recommendation from an External Expert Panel chaired by Harvard’s Professor David Bates and the conclusion from the Scottish Parliament’s Health and Sport Committee report on technology and innovation in health and social care that ‘the best way forward for data sharing is through a single platform, or spine, for data that other systems connect into’.
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PBC Work has progressed on this via NHS National Education for Scotland (NES) – the underlying ‘platform’ technology is a core part of the National Vaccine service, but it remains a long way from realising the full ambition of the ‘national digital platform’ and providing citizen and professional access to the right data at the right time. To address this, our 2021 ‘Care in the Digital Age’ Strategy introduced in more detail our programme of work for accelerating citizen access – via a ‘Digital Front Door’ (an existing PfG and Manifesto commitment) and, again joint with COSLA, our 2022 Data Strategy for Health & Social Care extended this further to incorporate the recognised need to develop an integrated social care & health record to enable professional access. Opening up citizen and professional access to relevant information has therefore long been a strategic commitment of both the Scottish Government and COSLA, and is supported by all stakeholders, international evidence and the Scottish Parliament. Whilst work on a number of the underlying capabilities continues to progress, the core ‘routes in’ for citizens and professionals to access (and meaningfully use) health & social care information – the digital front door and integrated record – don’t yet exist and as such will require major investment in their own rights and will be subject to their own detailed business cases. Given the significant dependencies between the NCS and these programmes of work (and the investment required), the ISCHR business case will align closely with the NCS programme governance and delivery arrangements. By focusing our technology developments on the sharing of information across health and social care, it is intended to establish an environment of collaboration across the public sector, positively impacting the ability to provide joint planning, risk sharing and oversight. It is also intended that by developing this in a national way, greater consistency and experiences of care will become more possible across Scotland – currently, a small (but growing) highly localised examples exist but not in a consistent, or equitable, manner. 2.4.2 Statement of benefit The NCS Programme. will build on the benefits contained in the statement of benefits as outlined in the policy memorandum. In tandem with the laying of the Bill in June 2022 a statement of benefit was published, this outlined the overarching ambition and strategic outcomes the NCS would deliver for the people of Scotland. Noting that “Care and support are an investment; they must work to remove barriers, tackle inequalities and allow people to flourish and live their lives as they want to.” The National Care Service will ensure consistency of provision and improvements in social care, social work, and community health support, by working in partnership with people who access and deliver services, trade unions, Local Government, and the third sector. Working in partnership agreement has been reached that overall accountability will be shared between Scottish Government, the NHS and local government. New governance arrangements in the form of a National Care Service Board will be introduced to ensure consistently high levels of service across the country, while building the flexibility to meet varying community needs at a local level.
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PBC 2.5 Delivery approach Co – design The Programme has committed to deliver change through co-design. By collaborating with people from all the different groups who will use and deliver services we can be more confident that the changes will work for everyone. As the Scottish Approach to Service Design outlines in this way we can design more responsive user-centred services by looking at the whole spectrum of needs created by life events. This not only improves the quality and efficiency of the services but improves outcomes for people who are trying to access services during stressful periods of change. We will design the services a NCS will deliver with the communities it will support in order to ensure it represents best value for money, through building the right improvements that will impact positively on the lives of the people of Scotland. Phased approach The Programme will build on current improvement work and ensure that opportunities to deliver impactful change now ahead of the delivery of an NCS are maximised. Current improvement work that the NCS is aligned to and will build on includes: “Getting it Right for Everyone” – new practice model that is person centred, human rights based and secures a proactive single plan, actions and support from all agencies involved in an individual’s life. Multi-disciplinary teams – originally set up to ensure health care is provided by the most appropriate professional, centred around GPs and Allied Healthcare Professionals. Has become a series of handoffs between professionals in most cases, rather than a team around a person. Opportunity to focus this on the GIRFE model and broaden out to include wider agencies. National Improvement Framework. o The Framework will provide focus and structure for efforts to drive improvements within the sector, giving flexibility for local areas to plan how to deliver and will be used at a national level to track progress. o This is being developed in partnership between the Scottish Government, COSLA and SOLACE with representation from across the Social Care Support and Community Health Sector to ensure the Improvement Framework captures the current and future needs across the system. The NCS Programme will take a phased approach building on the work above. Phase 1: will further define the Programme and options for delivery; deliver the NCS Bill; establish the National Board, National Social Work Agency (NSWA) and some national functions. Phase 2: will build on the work of the National Board and NSWA through embedding policy development and improvements through collaborative working. Phase 2 will also set the groundwork for local reform including development of the required secondary legislation. Phase 3: will see continued refinement of options for delivery of local reform. Options for delivery will be considered in more detail as part of the local reform business case and will include proposals for additional tests of change and phasing in Local Reform to support safe delivery and mitigate risk.
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PBC In line with the above approach principles for test of change have been developed to support the programme in successful delivery, these include: Continuity of Care and Public Protection must always be prioritised. Change should be gradual, and policy and delivery assurance through tests of change may be required before full implementation. Evaluation and exit strategies will be agreed at the outset. Pathfinder activity should align with similar objectives and activity already underway to avoid proliferation of national tests of change across the country. 2.6 Wider Strategic Risks Associated with the Delivery of the NCS The Management Case section sets out how risk will be assessed and managed throughout the lifetime of the Programme. Table 2 below sets out some of the wider strategic risks associated with the delivery of the NCS, but these must be read in the context that further work around the identification of risk will be undertaken as part of delivering this Business Case. Given the high level and strategic nature of the risks set out in Table 2 it is difficult to assess the likelihood and impact of these. Instead, they have been listed in order of how likely they are to crystallise, Table 3: Wider Strategic Risks Associated with Delivery Risks Affordability The change will require investment, which will need to be balanced against other priorities if it is to deliver the impactful long-term ambitions. Programme funding will require on-going management to ensure that budgets are effectively and efficiently utilised and that Programme delivery plans are regularly reviewed and adjusted, where necessary, to ensure that key programme milestones are delivered in view of future budget agreements and changing scope – including cost and resource requirements.
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PBC Risks Relationships The Programme requires cross government and public sector wide collaboration to ensure successful design, delivery and implementation of Health and Social Care Reform through the National Care Service. The agreement on shared accountability between Scottish Ministers, Local Authorities and the NHS will require the creation of new governance structures that should not introduce risk to existing governance, planning or delivery responsibilities. Technology Our current evidence base indicates that new technology will be required to deliver on the ambition of the Integrated Health and Social Care Record. Whilst this is not part of the scope of the business case the dependencies are such that the risk may impact on the NCS. This developing evidence base also indicates a mixed picture of digital maturity in the Social Care Sector and a need therefore to invest in the sector to improve digital capacity and capability to successfully implement the required technology. This therefore poses technology risks in terms of successfully developing the technology; ensuring any technology is sufficiently safe and secure for personal and special category data; and ensuring successful implementation of said technologies into the sector. Maintaining existing services The existing Health and Social Care System is already stretched, safely landing additional change in that environment will be a challenge. Careful planning and prioritisation of the phasing of change will be required in mitigation. Changes to the existing system must not result in a reduction of service quality or introduce additional risk to the services experienced by individuals. Public sector Interfaces for people do not improve. Implementing NCS delivers improvements in Health and Social Care but exacerbates the need for effective interfaces between Health Services (e.g. primary and secondary) and other public services such as housing and education. People There is a risk that the focus becomes system driven rather than focusing on the needs of people. The consultation provided an evidence base for change, but we must continue to put the needs of users at the heart of the change to deliver real and impactful change that meets their needs, supported by clear communication of the Programme’s approach to co-design. Localism There is a balance to be struck between the development of national standards, consistency, and transfer to new model of shared accountability to Ministers versus the flexibility needed to meet local geographic and demographic differences. Bureaucracy Creation of a national board without consideration of local delivery and improvement may be seen as an additional layer of bureaucracy, additional cost and layers of decision making as well as the risk of creating new artificial boundaries between services.
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PBC 2.7 Key Constraints and Dependencies This section sets out the key constraints associated with both the NCS Programme, and also considers the wider constraints associated with delivering the NCS alongside other Scottish Government priorities. Key Constraints associated with the NCS Programme There are three key constraints associated with the NCS Programme, these are explored in more detail at the headings below: 1. Resource Undertaking the NCS Programme will require considerable resources, both from the Scottish Government and from the Social Care Sector. Necessarily, the Programme will need to be delivered within the available resources. This Programme seeks to address complex issues within a complex system. Conducting the work necessary to deliver a service which addresses these issues require investment. The accompanying shared accountability paper sets out the anticipated financial resourcing requirements in detail. There is a resource constraint on the social care sector, which may limit the input available. There is heavy demand on a sector which is subject to its own resource constraints. Given the user-centred design approach which the NCS Programme intends to take, engagement from the social care sector is integral to the delivery of the Programme. 2. Stakeholders As set out in the previous section, the NCS Programme is aware of the demand on that sector, and the resulting resource constraints on the Scottish Social Care Sector. An additional constraint is the willingness of stakeholders to engage with the Programme, especially as their engagement is required to successfully deliver the change. So far, the NCS Programme has been able to access the necessary level of stakeholder engagement. The Programme will also have to balance the competing views of stakeholders e.g. balancing the views of system leaders, workforce, and service users. 2.8 Key Interdependencies for the NCS Programme The interaction between the Social Care Sector and the Third Sector will be a critical interdependency for the NCS Programme. The Scottish Government recognises that the care and support offered through the third sector community groups and third sector organisations of all sizes are central to ensuring that people who need care support, and their families, have the assistance with day to day living they need. This support also very often goes beyond regulated care provision to ensure a better quality of life-based on wellbeing and human rights. It is critical that this input is protected and promoted as part of future design. To deliver this, it is vital that the breadth of input from the third sector to the social care system is understood and incorporated. We must also consider the wider public sector reform landscape, and potential changes in the future, for example the development of the Single Authority Model, changes to the operating model of the NHS or wider reforms. The NCS legislation is being developed to enable such flexibility and to support wider reforms and the programme will remain engaged with these proposals as they emerge.
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PBC 2 Economic Case Introduction The NCS Programme is being developed in partnership with COSLA and the NHS. As such, the Programme continues to be defined through ongoing negotiations regarding respective responsibilities and practicalities around service delivery. Dependent on the final form that the NCS takes there is potential for substantial benefits to be realised from its introduction and the associated wider social care reform, committed to by the Scottish Government. This Economic Case quantifies what these could be and provides a framework for future detailed quantification of benefits as the programme develops. Future iterations of the Programme Business Case (PBC), and subsequent underpinning Business Cases, will outline the options for implementation of the NCS, following further decisions. At these points in time, the evidence around the economic benefits, as well as costs, will continue to be developed and refreshed and any gaps will be addressed. 3.1 Background The reform of Community Health, Social Work and Social Care has been a high-profile item on the public policy agenda in Scotland, over the last two decades. The intention to introduce a National Care Service (NCS) builds upon principles and ambitions that are well established, but which have not been fully realised to date. The rationale for the NCS is that the scale of transformation needed to meet aspirations for a rights-based, person-centred system that delivers a better experience and better outcomes for the people of Scotland, requires a fundamental, system wide change and a new approach to Community Health, Social Work, and Social Care. This would aim to go beyond both the individual and cumulative scale of reforms undertaken to date. 3.2 Current situation Demand for Health and Social Care services has been unprecedented in recent years and is expected to rise in the future. The current population structure includes a large concentration of people in their early-50s to early-70s.31 Owing to higher life expectancy, compared to previous generations, the latest projections suggest that the number of people aged 65 and over will grow by nearly a third by mid-204532. In addition to this, estimates of Healthy Life Expectancy (HLE) – the number of years an individual will live in ‘very good’ or ‘good’ general health – have been falling in recent years. It is now estimated that children (both male and female) born in 2018-20 will, on average, spend a shorter proportion of their life in good health, relative to those born in 2009-11.33 Whilst predicting the future demand for Social Care is extremely challenging, factors such as those highlighted here represent significant likely pressures on both Scotland’s current and future social care systems. The concurrent fall in the working age population puts additional pressure on public finances, making it even more challenging to achieve change and improvement. As such, it is critical that 31 Mid-2020 population statistics. 32 National Records of Scotland (2023) (link). 33 National Records Scotland (2022) (link)
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34 Independent Review of Adult Social Care (2021) (link)
PBC
the Scottish Government are able to respond in an efficient and cohesive way to deliver
consistent, high-quality Social Care Services, focused on the needs of the Scottish population.
At present, Local Authorities and Health Boards work together as Integration Authorities to assess,
plan and commission local Community Health and Social Care services in their local areas.
Integrated Health and Social Care is delivered through 31 Integration Authorities across Scotland.
Under these arrangements, Local Authorities remain statutorily responsible for the delivery of
Social Work and Social Care, and Health Boards for delivery of healthcare, on behalf of the
Integration Authorities. Scottish Ministers have limited statutory responsibilities for the delivery of
Social Care and Social Work Services locally.
3.3 Independent Review of Adult Social Care
The case for reforming the delivery of integrated health and social care arose out of an
Independent Review of Adult Social Care (IRASC)34. Conducted in the latter half of 2020, and
published in February 2021, the report concluded that whilst there were strengths in Scotland’s
Social Care system, it required revision and redesign to enable a step change in the outcomes for
people in receipt of care or accessing Social Care support. The critical role of Social Care, in
supporting people to live well and to have their rights respected, was further demonstrated starkly
during the Covid-19 pandemic.
The challenges identified by the IRASC included:
Inconsistency of user experience ("postcode lottery")
Complex and inconsistent governance arrangements
Lack of national oversight and collaboration
Lack of collaborative and strategic leadership
The need for a paradigm shift in care support to one underpinned by rights.
Non-integrated budgetary and financial planning
The IRASC report found that the current arrangements for delivery of Integrated Health and Social
Care by Health Boards and Local Authorities, means that lines of accountability are not clear, and
this results in complexity in the system and poorer services for people. The IRASC concluded that
fundamental changes were needed regarding who is responsible for delivering Social Care in
Scotland and how that delivery is organised. This is because, although incremental reforms have
been ongoing for a number of years, people accessing Social Care support are still faced with
significant challenges in securing the services they need.
3.4 Options
This section presents the risks of continuing with business as usual and the additional benefits of
introducing the NCS.
3.5 Option of Business as Usual
IRASC identified that many current costs in Social Care are driven by crisis management and late
interventions. An example of these, and related poor outcomes, are those experienced by people
who are delayed in hospital. It is estimated that delayed discharges cost the system £134 million aPage 106
35 Independent Review of Adult Social Care (2021) (link) PBC year, plus the wellbeing loss experienced by individuals.35 This is an illustration of one of the costs of the current system that could potentially be mitigated against by improving on business as usual. If the IRASC recommendations are not implemented and we continue with piecemeal reforms to the Social Care system, then there are risks that increasing inefficiencies could cost more than investment in a new delivery system. A new system which enables strategic integration, national oversight, and accountability, would provide opportunities to invest in preventative care, rather than crisis responses, avoiding expenditure on poor outcomes such as those experienced by people who are delayed in hospital. When instances such as this are considered across the whole social care, social work, and community care landscape, there could be considerable costs that are avoidable if the current system can be improved to better support the health care system and relieve pressures here. Without a better developed social care system, pressure will continue to mount on the NHS and there will be increased costs both of treatment and impacts on patients. Not only are there risks to continuing with business as usual due to the current pressures on the health and social care systems, but these risks will be compounded by the forecasted increase in demand, discussed above, as a result of the aging and worsening health of the population. Continuing with business as usual becomes increasingly risky, as the system reaches breaking point. As this increased demand for social care services starts to materialise, it is likely that service quality will decrease under business as usual. 3.6 Option of The National Care Service The Scottish Government is aiming to implement the recommendations from the IRASC through ongoing social care reforms and the creation of the NCS. It is hoped that this will allow Scotland to be better equipped to tackle both current and future issues in health and social care. So far, agreement has been reached to establish an NCS Board as the primary means through which to operationalise and manage shared accountability. Discussions are still ongoing around the NCS Board including membership. The Board will, amongst other things, determine the national strategic direction; set standards, guidance, and operating frameworks; monitor system performance; and provide a framework for support, improvement, and intervention. Further work and co-design is required to set out how the NCS National Board’s monitoring and oversight functions will work in practice, and how those functions will align to, and interact with, those community health, social work and social care support services agreed to be within the scope of the NCS. At the local level, it is expected that the existing IJBs will be reformed. These reformed IJBs will have additional functions to deliver reforms, such as: a new independent chair who will be accountable to the NCS Board; support for lived experience representatives to ensure unpaid carers are able to attend board meetings; and improved consistency in the role of locality managers.
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36 Measures of National Well-being Dashboard - Office for National Statistics (ons.gov.uk) PBC 3.7 Costs The Financial Memorandum and shared accountability paper provides information on the cost estimates for the NCS Programme, as described in the Bill. 3.8 Benefits This section outlines the potential benefits that may result from the NCS legislation and Programme. These benefits cannot be quantified at this stage and there remains a high level of uncertainty over the design of the remainder of the NCS. However, where possible, we have provided illustrative figures to demonstrate the scale of benefits that could be in scope, depending on the delivery of the NCS, to accompany the qualitative discussion. The three key pillars through which the NCS will deliver benefits, as outlined in Stage 1 of the Bill, are: consistency, integration, and accountability. The NCS will enable people to access timely, consistent, equitable and high-quality health and social care support across Scotland. The NCS is intended to continue the integration of health, social work, and social care support to deliver benefits, both to those working within and those accessing social care, as well as to wider healthcare services and society as a whole. There will be improved accountability in the system through the role the NCS Board itself will take in monitoring system performance and driving a transparent framework of support, improvement, and as a last resort, intervention, in cases of service failure or emergencies. The impact of these pillars are subsequently considered in two parts: the direct benefits of the NCS; and the benefits of wider reform that the NCS enables to be maximised. It is expected that these benefits would accumulate gradually over the next decade, rather than immediately after the introduction of the NCS. Direct benefits of the NCS This section illustrates the direct benefits that the NCS could potentially deliver to those receiving and providing care, through shared accountability; consistency; and integration. These benefits come about through generating improved wellbeing outcomes of several groups. Wellbeing Wellbeing is defined by the Office for National Statistics (ONS) as “how we are doing” across ten domains of wellbeing, as individuals, communities, and a nation, and how sustainable this is for the future.36 Personal wellbeing, which is concerned with the experience of the individual, is the most direct representation of how people are doing. Measures in this domain, as set out by ONS, cover people’s views on their current life satisfaction, whether the things done in life are worthwhile, and their happiness and anxiety levels. It is held that improvements to these ratings represent a benefit to the individual in question.
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PBC It is important to understand this, as it is hoped that the NCS will help deliver wellbeing benefits to those involved – both receiving and providing support – in the social care system. The current context in the UK, is set out in ONS personal well-being statistics.37 Focusing on Life Satisfaction, the latest estimates show that individuals in the UK, on average, scored 7.45 out of 10 in the year ending March 2023, with scores of those living in Scotland marginally higher at 7.49.38 Individual’s characteristics and circumstances can have a tangible impact on their relative score. Across the UK, those that reported themselves as having Bad (Very Bad) health, some of which may be recipients of social care, reported significantly lower levels of life satisfaction of 5.86 out of 10 (4.65 out of 10). The section which follows looks to outline how it is anticipated that the NCS Principles will help to deliver wellbeing related benefits. For individuals receiving care The NCS Board will drive national strategic direction and provide standards and guidance to address unwanted variation in the system, and drive improvements in the care delivered. The presumption in favour of further integration recognises that any transitions individuals receiving care go through – be it in terms of geography, age, stage, or between health and social care services – should be smoother. By strengthening the voice of lived experience in planning and decision making, health and social care services that better meet the needs of users will be provided. For those working in care Through mechanisms, such as the establishment of a National Social Worker Agency (NSWA), it is expected that the policy will support the social work sector. This should drive improvements in workplace standards, leading to overall improvements in job satisfaction levels. For those working in social care, the expectation is that locality managers, engaging the community to a greater extent, will improve the channels through which carers can raise concerns to the reformed IJBs. Alongside this, consistent training and career opportunities should be provided, enabling an improvement in the experiences of the paid workforce, regardless of what part of Scotland they are based in. Continued integration means that information flows and communication should improve between health and social care services, making it easier for staff to manage transitions and improve working relationships. 37 Personal well-being in the UK - Office for National Statistics (ons.gov.uk) 38 People living in communal establishments (such as care homes), or other non-household situations are not represented in the APS and, subsequently, are not captured within reported figures on personal wellbeing (link).
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PBC Improvements to wellbeing Illustrative examples of improvements to wellbeing are provided below, for those who receive care and for those who work in Adult Social care. In line with Green Book Supplementary Guidance, the potential annual benefit from an improvement in wellbeing can be monetised.39 This guidance proposes that a one-point change in life satisfaction, measured on a scale of 0 to 10, has a central value of £13,000 (low: £10,000, high £16,000) (2019 prices), per person per year. This is referred to as a 'wellbeing adjusted life year’ or ‘WELLBY’. For illustrative purposes, we look at the benefit that could be derived from a 0.1 improvement in wellbeing (equivalent to 10% of a central WELLBY), for 10% of each of the different groups. In 2021/22, there were 236,000 people in Scotland reportedly receiving social care support or services.40 If it is assumed that 10% of this group (23,600 people) experience a 0.1 point improvement in wellbeing because of the establishment of the NCS for the reasons discussed above, then this could lead to a potential annual benefit of around £34 million (2021 prices). In 2021, there were around 130,000 people employed in the Adult Social care sector.41 If it is assumed 10% of this group (13,000 carers) experience a 0.1 point improvement in their wellbeing on the life satisfaction scale because of the establishment of the NCS, then this could lead to a potential annual benefit of around £19 million (2021 prices). These are illustrative examples and are not intended to be used as true estimates, rather to demonstrate that there is potential for substantial benefits depending on how the NCS is implemented. The actual benefits which materialise could vary considerably depending upon the number of people who benefit and the scale of benefits that accrue to individuals. Additionally, whilst these illustrative examples look to monetise the potential benefits to individuals' wellbeing, it is important to recognise that they are non-cash releasing. This means that whilst there are quantifiable benefits they do not lead to a direct reduction in spending or increases in incomes. Benefits of the NCS maximising the benefits of wider reforms. The establishment of the National Care Service, and the potential direct benefits it may bring, should also be considered alongside the wider social care investment that the Scottish Government has committed to. This includes increasing adult social care pay to £12 an hour, reopening the Independent Living Fund, removing charges for non-residential social care, and overhauling eligibility.42 By driving national improvements and bringing national oversight and accountability to the sector - it is expected that the NCS will enable additional investments to go further and provide high quality care for more people than otherwise would be the case. If the NCS enables wider social care 39 Green Book Supplementary Guidance (link) 40 People supported - Insights in social care: statistics for Scotland - Support provided or funded by health and social care partnerships in Scotland 2021/22 - Insights in social care: statistics for Scotland - Publications - Public Health Scotland 41 This only includes those working in adult day care, adult placement services and housing support/care at home. It does not consider health workers: Scottish Social Services Council, August 2023 (link) 42 Programme for Government 2023 to 2024 (link)
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PBC reform to potentially reach those currently outside the formal care system, there are two main groups who would benefit further, those with unmet need and unpaid carers. This section illustrates the potential marginal benefits that could be realised by the NCS, when paired with wider policy reform which increases the provision of social care in Scotland. It is important to note that provisions for such wider reform are not matched by costs set out in the financial memorandum. Costs for increasing provision will instead be covered in individual policy costings, for the wider reforms. Unmet need and unpaid carers Currently, the social care system primarily provides support to those with critical or substantial needs. Through wider social care reform, the Scottish Government has committed to overhauling eligibility criteria, changing to a human rights approach that centres around need, rather than using eligibility as a tool to control budget. It has also committed to removing the financial deterrents for accessing such care. As such, it would be expected that social care within Scotland will reach further and provide support to more people – including those with current “unmet needs”. For these reforms to be effective, and to reach the large sub-population of unmet need in Scotland, the social care infrastructure and governance that the NCS will bring needs to be in place. As such, it is plausible that the NCS will enable greater benefits to be achieved for those currently with unmet need. IRASC estimated that, in 2018/19, there were 36,000 people in Scotland who “do not currently have access to social care support to whom it would be beneficial”.43 and44As an illustrative example, if it is assumed that 10% of this group (3,600 people) were to experience a 0.1 point improvement in their wellbeing on the life satisfaction scale, the potential annual benefit could be around £5 million (2021 prices).45 People with unmet need are not the only group, within the informal care system, who could benefit in such a way. There are estimated to be around 839,000 unpaid adult carers living in Scotland.46 Evidence shows that that these unpaid carers often experience lower earnings, and lower levels of physical health than non-carers.47, 48 If the NCS where to enable a greater proportion of the people that unpaid carers care for to access formal care (beyond that which a care system without an NCS is able to) and reduce their unpaid caring needs, it is plausible that the NCS could lead to improved health outcomes for unpaid carers. The benefits which materialise could vary considerably depending on the number of people who benefit and the scale of benefits which accrue to individuals. Young carers Another group that could benefit from the introduction of the NCS is young carers, who are a sub- group of the unpaid carer group. As stated above, if the introduction of the NCS leads to a greater proportion of the people that young carers care for, being able to access formal care and 43 Independent Review of Adult Social Care (2021) (link) 44 The figures quoted are likely to under-estimate the scale of unmet need. However, work is ongoing to improve evidence around unmet need. 45 HMT Green Book, Supplementary Guidance (link) 46 Number of adult carers (aged 18 and over) living in Scotland 2020: Scottish Health Survey (link) 47 Brimblecombe N., Knapp, M., Stevens, M., & Cartagena Farias, J., (2020). The high cost of unpaid care by young people: health and economic impacts of providing unpaid. BMC Public Health, 20:1115, https://doi.org/10.1186/s12889-020-09166-7 48 Thomas, G.P.A, Saunders C.L., Roland, M.O., & Paddison, C.A.M. (2015). Informal carers’ health-related quality of life and patient experience in primary care: 195,364 carers in England responding to a national survey, BMC Family Practice, 16:62, DOI 10.1186/s12875-015-0277-y
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PBC subsequently reduce their unpaid caring needs, then there are potential benefits specific to young carers, regarding their educational participation and attainment. Over a quarter of young carers in the UK, aged 11 to 15, are reported to regularly miss school due to their caring responsibilities and, when they do attend, that the burden of their caring responsibilities can adversely affect their levels of tiredness and concentration.49 This can have a lasting effect on their life chances.50 If the NCS enables young carers to reduce the number of hours of care which they provide, beyond that achieved in a system without an NCS, not only could this lead to health improvements (similar to those discussed for wider unpaid carer group), but it could also lead to improvements in their educational attainment. This could then have a knock-on effect on the quality of their future employment and earnings, labour force participation, and ultimately the taxes they pay. This is an area that needs greater exploration, in order to understand and quantify the potential benefits. Wider benefits If formal care can replace care that is currently provided by unpaid carers, then this could potentially lead to wider benefits too. Insights taken from Scotland’s Carers Census reported that 30% of unpaid carers reported that caring had affected their employment51. These proportions were higher for those between the ages of 25 to 65 and how they were impacted, varied both in scale and by gender. By reducing the barriers to individuals’ ability to work more hours or take up new jobs, it can be assumed that there would be an associated increased participation within the labour market. This is an area that needs greater exploration, in order to understand and quantify the potential benefits. Any such increased participation in the labour market would be expected to have wider benefits for society. For example, such individuals will receive an increased disposable income. This will then lead to increased spending and saving of individuals, contributing positively towards economic growth. Additionally, there may also be benefits to the state of increased revenue (through additional tax receipts) and potential savings (through reduced provision of benefits, for example, Carer’s Allowance). Another key area of benefits resulting from the NCS is the possibility of efficiency savings. This need not be that overall costs fall, but that costs per unit of social care falls. If improved management, integration of services or general logistics led to even relatively incremental time savings for staff, then this could have substantial benefits across the system. Further analysis into the scope and scale of these wider benefits will be carried out, to support the further development of both the Programme and underlying businesses cases. 3.9 Risks As options have not been evaluated at this stage, it has not been possible to quantitatively assess risk. However, we have identified risks that would warrant further investigation in future Business Case iterations. Risk categories are drawn largely from standard Government guidance and include risks in funding and design from additional costs that may arise; reputational risks if standards are not 49 Action for Children (link) 50 Action for Children (link) 51 Carers Census, Scotland, 2021-22 - gov.scot (www.gov.scot)
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PBC met; operational and volume risks stemming from higher workforce costs or over utilisation of services; commercial risks due to difficulties in transitioning of services; and environmental risks from having to meet net zero targets. It could be argued that the introduction of the NCS offers greater mitigation against, for example, the potential risk of reputational damage by actively implementing measures that prevent standards from not being met. There is therefore less chance of that reputational damage and a lower overall risk score. Conversely, it can be argued that continuing with business as usual will become increasingly risky, as the system reaches breaking point. Establishing an NCS could enable the system to deliver care in a more efficient way, which in turn would result in a lower risk of the system reaching crisis point. 3.10 Next steps/conclusion There is potential for substantial benefits to be realised from the NCS, and the associated wider social care reform, committed to by the Scottish Government. This Economic Case illustrates the potential scale of these benefits and provides a framework to enable future detailed quantification of benefits as the programme develops. Discussions between the Scottish Government, COSLA, the unions and the NHS have been still ongoing. Once these have concluded, the implications of these discussions are understood, and subsequent options for how the NCS will be implemented are known and developed, we will refine this Economic Case and those in future underpinning business cases. This will provide more detailed analysis on the scale of benefits that each option provides compared to its costs to provide a value for money assessment. We will continue the development of the evidence base for the NCS, to ensure informed decisions are made that offer best public value to society.
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PBC 4. Commercial case 4.1 Overview This Commercial Case section recognises that to support the NCS Programme two main strands of procurement activity are likely to be required. Firstly, there will be a requirement to engage procurement colleagues in activity related to the processes and timescales that will inform the purchase of goods or securing of services as required to establish the National Care Service National Board including any support services. Secondly, procurement professionals will also be engaged in the purchase of services such as user research, professional advice, and stakeholder engagement related services as need is identified, to support the NCS programme. This will include supporting the ongoing co-design and policy development, meeting the commitment to design the detail of the NCS with people with lived experience, the workforce and key stakeholders including delivery partners. As individual requirements for key procurements become clear, market engagement and Statement of Requirement activity will be described in Commodity Lead Procurement Strategies that relate to those workstreams (rather than in the Programme-level Business Cases). That work, and those Commodity Lead Procurement Strategies will ensure that procurement activity is compliant with procurement legislation and standards, including Digital Scotland Service Standard (DSSS), sustainable procurement standards, fair work first, and data security considerations - from both the programme and the supplier’s perspectives. It is recognised that Procurement colleagues are key stakeholders not only in the delivery of the Programme policy and outcomes but also as prospective supportive stakeholders of the future delivery boards in live running. Procurement colleagues are also leading projects within the programme including the reform of procurement guidance and tools to embed an ethical procurement approach, working with colleagues on how procurement will be delivered within the national care service, and the development of a market shaping approach. As the National Care Service Programme continues to develop, its requirements for key procurements and commercial relationships will change and develop to meet the Programme’s evolving needs. The nature of this Programme, close working with policy teams across it, and comparisons with similar recent programmes in the Scottish Government (particularly the Social Security Programme) has informed this Commercial Case and reasonable predictions of the types of services that will be required to be made. Commentary on sourcing those services is provided below. Scottish Government Procurement Strategy The Scottish Procurement and Property Directorate (SPPD) has published its Procurement Strategy for 2022-24. As part of the core Scottish Government, the NCS Programme is bound by that Procurement Strategy. The Programme will be supported by The More Powers Implementation Procurement (MPIP) team which acts in accordance with this strategy when acting for the Programme. The Scottish Government Procurement Strategy notes that the Scottish Government’s key priorities are centred on contributing to Scotland’s purpose of creating a more successful country, with opportunities for all to flourish, through increasing sustainable and inclusive economic growth. This is underpinned by the National Performance Framework, Scotland’s National Strategy for Economic Transformation (NSET) and the annual Programme for Government which sets out the plan for policy delivery, public procurement priorities and legislation over the next year. It ensures compliance to, and delivery of the priorities through the sustainable procurement duty as outlined in Procurement Reform (Scotland) Act 2014. Our strategy continues to support the Scottish Government’s work on addressing climate change, supporting, and embedding a fair work first approach, tackling child poverty, delivering COVID-19
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PBC recovery, and building our constitution. The sustainable procurement duty helps public sector organisations identify opportunities to include economic, social, and environmental considerations in contracts and show how our procurement activity contributes to the National Outcomes and Indicators and, in turn, to Scotland’s NSET. We develop sourcing strategies for each procurement project worth £50,000 or more. This work is supported by the Sustainability Test and, where appropriate, the Sustainable Public Procurement Prioritisation Tool (SPPPT). We track our contribution to the Scottish Government’s purpose and priorities through our compliance with the sustainable procurement duty. In doing so the Programme ensures our activity furthers our Procurement Strategic Aims and Objectives such as. Tackling Child Poverty through Fair Work First. Our vision is that by 2025, people in Scotland will have a world-leading working life where Fair Work drives success, wellbeing and prosperity for individuals, businesses, organisations, and society. We use public procurement to tackle in-work poverty and, by extension, child poverty by ensuring job security and fair pay in our contracts. Climate change. Our sustainable procurement tools include indicators and guidance to support Scottish public sector buyers to consider and act on several climate change and circular economy considerations. We are committed to acting on climate change and to develop the circular economy by buying goods and services which reduce emissions, minimise waste and allow for repair, re-use, refurbishment, or recycling wherever appropriate. Covid recovery. The strategy covers commitments described in Scotland’s National Strategy for Economic Transformation and Scotland’s Programme for Government. This includes using the £13.3 billion annual procurement spend across the Scottish public sector to boost inclusive economic recovery, support longer term economic wellbeing, and a just transition to net zero. Our tools and guidance will influence and empower buyer, supplier, and key stakeholder communities to use public procurement to support an inclusive and green economic recovery. The strategy is underpinned by detailed guidance on each stage of the Procurement Journey (phases of activity). 4.2 Commodity level Procurement Strategies Commodity level Procurement Strategies set-out the approach to buying the goods, services and works in a series of procurements. These strategies are bespoke on a procurement-by- procurement basis and include sections on the choices of procurement procedure or potential payment mechanism as these will be defined in each commodity level procurement strategy to suit the needs of the individual contract. These Procurement Strategies are aligned with the Scottish Governments overarching procurement strategy. 4.3 Work Streams, Forward planning, and Required Outputs The Programme level picture of procurement requirements will constantly evolve as projects mature.
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PBC The Programme has so far identified requirements such as research, consultation analysis, professional advisors, contingency labour, and digital expertise. Commodity-level Procurement Strategies will be developed for each of these when the value is greater than £50,000. As the Programme is already in operation, contracts for these types of services have already been secured for the Programme. For each of these service types, the work to date has demonstrated sufficient market capacity and multiple routes to market, including existing frameworks, Dynamic Purchasing Agreements, and open competition. There are no current issues regarding the interdependency between pace and scope of the Programme and MPIP’s ability to secure the required services through these routes to market. MPIP in conjunction with the Programme will develop a procurement Forward Plan and contracts register of detailing priority contracts. The Programme procurement ‘Forward Plan’ is a live document and will assist the Programme to plan for future procurements, manage contract relets, manage resources, and understand which projects should be considered prioritised. 4.4 Property requirements No property is intended to transfer from Local Authorities to establish the National Care Service, but the National Care Service may have property requirements (for example, occupying space in existing Scottish Government offices). Scottish Procurement Property Division continue to advise on property requirements for the Programme. Property Division will support the Programme in appointing appropriately experienced external advisors and are managing the delivery of professional services for property matters for the Programme. The Chief Surveyor leads commercial advice in relation to the acquisition of Property for Scottish Government Core Directorates and Agencies. 4.5 Digital requirements The Digital Strategy for Scotland, “A Changing Nation: How Scotland Will Thrive In A Digital World” sets out the role digital will play and this, together with other relevant digital strategies such as Cyber Resilience underpin our approach to digital procurement activity. When appropriate, the MPIP team undertake pre-market supplier engagement to ensure that the market is aware of future procurement activity prior to the publication of tender documents. This is designed to increase supplier participation in the procurement process and provide increased opportunities for the delivery of innovative digital solutions and de-risk delivery outcomes. In delivering the procurement of projects including digital platforms and software, the agile approach is used predominately. 4.6 Governance Relating to Procurement and Commercial Activity Delegated Purchasing Authority (DPA) is the authority to enter into a contract for goods, services and works and applies to all contracts placed by the Scottish Government. Purchasing Authority is separate from budgetary authority and the two cannot sit with one individual. This is common across both public and private sectors and is standard fraud prevention measure. A Budget Owner can decide to allocate funding to a particular initiative, but they cannot award a procurement contract. Delegated Purchasing Procedures must be followed for all procurement exercises:
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PBC Delegated purchasing authority for low level spend (i.e., contracts valued under £50,000) typically sits with trained (Delegated Purchasing Officers) Programme officers and is supported by the MPIP team where required. Regulated procurement activity (contracts worth £50,000 or more) is managed by the MPIP Team. The Head of MPIP has a commercial delegation of £75,000,000 ex VAT and is ultimately responsible for the commercial due diligence of contract awards up to this value. DPA of higher values sits with other officers in the Scottish Procurement and Property Directorate and they will be drawn-into the governance of high-value projects as required. 4.7 Governance Relating Budgetary Approval The National Care Service Programme Budgetary Governance is described in the Management case section.
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PBC 5. Finance Case For the purposes of this version of the case the accompanying shared accountability paper should be referred to.
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PBC 6. Management Case 6.1 Introduction The approach to management of the Programme is set out below. Scottish Government, Director General of Health, and Social Care (Accountable Owner) are delivering the Programme. A Senior Responsible Officer (SRO) leads the Programme, the Director of the Social Care NCS Development Directorate. The cross-cutting nature of the Programme requires collaborative working across the Scottish Government, Local Authorities, NHS, and the wider social care sector to develop policy, design and implement an NCS that brings together community health and social care to improve the service for the people of Scotland. The preferred programme management methodology is a hybrid model supported by Managing Successful Programme (MSP®), using both agile and waterfall methodologies. Agile methodologies will be used where an iterative approach is required, with waterfall methodologies adopted where a linear and more traditional approach is preferable. The sections below set out how this methodology is applied. 6.2 Programme and Project framework 6.2.1 Programme high level structure A Programme structure has been developed, which sets out the Programme, scope, underpinning projects, which will include detailed workstreams and programme functions. This sets out what the programme will deliver. Figure 2: Scope For the purposes of this PBC, the management case section applies to all projects and workstreams which will contribute to the delivery of the NCS. Further evidence will be considered on the inclusion of Children and Families and Justice Social Work as well as final decisions on the community health services that will form part of the NCS. The programme planning assumption is that all areas are in scope until such time as a final decision is made, this is essential to ensure
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PBC their needs and any impacts are fully considered. Each of these areas will be represented in the teams delivering the Programme, projects and workstreams. Level 1 Programme The Programme refers to all projects, work streams and functions required to deliver the NCS, the Programme SRO is accountable for the successful delivery of the Programme and its expected benefits and outcomes, they have delegated responsibility for underpinning projects to Project Responsible Owners as outlined below. Level 2 Projects The Programme will deliver a fully integrated NCS, for the purposes of delivery and good governance five overarching projects have been identified that underpin the successful delivery of the Programme. These are NCS National Board, National Social Work Agency, National functions, Local reform. The Integrated Social Care and Health Record is also listed here given the significant dependencies between the projects. As a major project, it will have its own governance arrangements that will be embedded with the NCS Programme. Each project has a project responsible owner who is accountable for the successful delivery of the project, underpinning workstreams and expected benefits and outcomes. In line with the Programme’s business case strategy, where appropriate, each project will be supported by a business case. Level 3 Workstreams Sitting below the projects are a number of interdependent workstreams. Each workstream will have an identified owner that aligns with the Programme governance and accountability structure. Programme functions In addition to the workstream delivery, the Programme requires functional teams who will ensure common programme management processes are applied consistently across the programme, the expectation is that these will cease at programme closure. Some examples of functional teams in the current Programme are: Communications and Engagement Analytical Services Co-design Finance Change management. Programme Management Office 6.2.2 Appointed Personnel and vacancies The Programme has appointed an Accountable Owner, Senior Responsible Owner, Project Responsible Owners and workstream leads.
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PBC Figure 4 – Senior Team The figure above shows the senior team responsible for delivery of the NCS and the critical dependency of the Integrated Health and Social Care Record. The senior team are supported by workstream and functional leads. As outlined above, the programme is led by the Senior Responsible Officer (SRO) who, in line with the Scottish Public Finance Manual (SPFM), has delegated responsibility from the Accountable Officer for the successful implementation of the Programme, with Scottish Ministers remaining accountable for policy. The SRO is supported in successful delivery by senior civil servants with considerable experience in all areas in scope of the NCS as well as specialism in digital, design, user research, analysis, legal and project management. In recognition of the wide scope and complex governance of the National Care Service Programme the Programme Management Office are putting in place a bespoke Senior Responsible Officer delegated authority which will be supported by Director level Programme Responsible Officers from across Scottish Government. In addition, the Programme leadership is supported by the advice and guidance of a range or professional advisors who provide expert input and advice on the role of the professions within the current sector. An embedded Programme Management office ensures robust governance and reporting processes are in place to support the successful delivery of this Programme. 6.3 PMO Governance and Reporting Arrangements 6.3.1 Reporting Arrangements The NCS Programme has in place robust reporting arrangements, in line with the programme structure and hierarchy outlined above, proportionate reporting arrangements are in place at workstream, project and programme level. Workstreams report into regular project working groups, covering progress against plans, and risks and issues. In turn projects report into the Programme Delivery Board (PDB) on a fortnightly cycle. The PDB tracks and monitors progress against plan, risks and issues and programme costs. In addition, the Programme provides a report to the dedicated programme assurance board and to Minsters via the Cabinet Sub Committee. All Programme reporting arrangements support SG corporate reporting.
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PBC 6.3.2 Scottish Government Internal Governance Arrangements The programme has established an internal governance structure to support programme delivery and enable timely decision-making at an appropriate level of authority, providing assurance to senior stakeholders and Ministers. The internal governance arrangements and Ministerial oversight support the cross-cutting nature of the Programme through having representation from all areas in scope or impacted by the NCS. The Programme Delivery Board is the Programme’s main decision-making board for implementation decisions. It is here where the SRO is given assurance that project deliverables and milestones are being delivered. Above the Programme Delivery Board, sits the NCS Assurance Board, acts as an escalation point for the PDB. This provides senior cross-Government assurance to the Scottish Government Executive team that the Programme is managed effectively. Additionally, the Programme has established governance forums subordinate to the PDB, these include project working groups, the risk review panel and co-design assurance group which work with designated authority from the PDB. Project Working Groups provide detailed oversight and governance at a project level, reporting into Programme level governance via the PDB. The Risk Review Panel provides management and oversight of the Programme risk profile to ensure threats to Programme objectives are minimised and opportunities maximised. The Co- Design Assurance Group’s role is to ensure that a consistent and co-ordinated approach to co-design is being taken across the programme. The Group also manages the administration for the Lived Experience Panel and the NCS Stakeholder Register. Parallel to the internal governance structures within the NCS programme, there are several forums for engagement with external stakeholders, those who access and work in care and organisations. There will be a need enhance governance arrangements as the Programme progresses to support the development of shared accountability through the national board, this will be likely to include representation of key delivery partners. Figure 5: NCS Programme Governance Landscape
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PBC 6.3.3 Programme Management Office (PMO) The Programme is supported by programme functions including a Programme Management Office (PMO) that provides support, coordination, and control across the Programme. The PMO consists of a central team led by the Programme Manager and overseen by the SRO. It delivers consistency across the programme by developing and maintaining a set of PMO strategies which set the standards for all programme management functions. All PMO owned strategies, processes, artefacts, and templates are living documents and are maintained and updated regularly. In the initial phases of the Programme, the team oversee standards and processes including in the following areas: Programme Governance, Reporting and Secretariat Planning and dependency management Programme Assurance Resource management Risk and Issues Change Control Benefits Realisation 6.4 Programme Planning This section will outline the programme approach to planning and dependency management, including the high-level programme schedule of delivery, the programme phases and change management approach, and how it will be monitored and controlled. In addition, the section will provide an overview of the Programme’s approach to underpinning business cases to support future investment decisions and the Programme costs. 6.4.1 Programme Schedule The National Care Service is a significant transformation programme and will be delivered over several years. The programme is structured to deliver in phases, supporting the need for early improvement balanced with the need to maintain continuity of safe care. The current priority for the NCS programme is to support the passage of the Bill and secondary legislation during this Parliament to create a strong framework for the future delivery of social care across Scotland and putting in place the enabling functions that will allow the programme to implement the programme deliverables on a phased basis. The programme phases are supported by the agreed co-design process. Through co-design and phasing the Programme is working to ensure that we close the ‘implementation gap’ between legislation and delivery as highlighted in the Independent Review of Adult Social Care. Figure 6: High level route map & programme phasing
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PBC Programme planning strategy. The programme high level route map for delivery will be supported by the Programme planning strategy which outlines the three-level approach to planning, programme, project and workstream, that supports successful delivery through consistent application of planning controls. Programme phasing As outlined in the figure below the Programme will be delivered in phases. This supports the Programme to prioritise continuity of safe care. This ensures that much needed improvements can be rolled out ahead of full reform whilst mitigating the risk of landing significant change on an already stretched sector. The phased approach allows for co design, test of change, and evaluation of change to support decision making on future change activity. The starting point is not the same across Scotland, with some Integration Joint Boards already operating with full delegated powers for both children’s health services, children’s social care services and criminal justice social work services. The Programme’s phased approach will protect these existing partnerships and ensure we do not inadvertently roll back on the commitment to integration that supports people. The Programme approach to phased transition will reduce the risk of transfer and support co-design and inclusion of local areas. It may be that for some localities, change can be implemented in advance of the timelines set out in the current planning assumptions. 6.4.2 Business Case approach The NCS business case approach will follow HM Treasury Green Book methodology in developing proposals for the scope, planning and delivery of the NCS programme.
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PBC The PBC seeks to outline the key decisions made to date, the scope, case for change, overarching strategic benefits and funding envelope required over the lifecycle of the Programme. The case also outlines how the Programme will be managed and the phases of delivery. The case will be an iterative document and updated at key phases of the Programme as options for delivery develop. The PBC will be underpinned by project business cases that will provide additional detail to support investment decisions in line with the phases of the Programme. Figure 8: Business Case approach NCS B SINESS CASE APPROACH 6.5 Co-design Co-Design Approach The Programme has committed to deliver change through co-design. This approach will involve engaging with three key groups through its co-design activity. People with experience: This includes people who need health and social care support and their friends and family, people who deliver health and social care support and people who might need support in the future. People with experience matter because people’s experiences of how the current system works help us to think together about what a future system of care might look like. What is happening in people’s lives can affect their health and social care, or their work in health and social care, so it’s important we think about that too. By collaborating with people from all the different groups who will use and deliver services we can be more confident that the changes will work for everyone. Participating in things like this is also an important human right. Integrated Social Care & Health Record Business Case Underpinning Business Cases OBC/FBC Local reform National Social W ork Agency National Board Purpose Set out the: Scope Funding envelope Phases of the Programme that align with the annual budget setting process Programme Business Case Phase 1 Phase 2 Phase 3
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PBC Delivery partners: This includes the organisations which deliver social care services and organisations that support social care services. Delivery organisations matter because organisations that provide health and social care services locally, or support other organisations to do that, understand the opportunities for change in the current system, they also understand where there are barriers to change, and what works well. They are vital to helping us be sure that proposed changes can be put in place. Stakeholder organisations: This includes organisations that represent different communities (organisations that represent communities that might find it harder to connect directly with publicly promoted co-design activities) and organisations that have a key connection to social care. Stakeholder organisations mater because they have a great deal of knowledge about groups of people who access health and social care support, or deliver health and social care support, and about particular issues that affect the delivery of care. They are also in a unique position to promote or conduct co-design activities with communities with whom they have trusted relationships, increasing access to communities that might find it hard to otherwise engage in the process. Combining the views of all three groups, creates a rich set of ideas and insights from many different points of views to inform decision making. To deliver this approach the Programme will structure the co-design activity in phases. These are as follows: Understanding: Thinking about what needs to change and why. Looking at the data and evidence that exists and agreeing what it tells us and where more is needed. Considering the things that will impact what change can happen. Making sense of information and coming up with ideas (sometimes now as ‘Sensemaking’): Generating ideas about what could change, how change might work, look, and feel. Testing out ideas for changes and making sure they will work in practice. Agreeing: Helping to check that proposed decisions that result from the work of understanding and imagining are the right ones. This would also include ensuring that proposals are affordable, legal, deliverable, and proportionate. Drafting of regulations / service design: Co-design conclusions will be developed into regulations where appropriate or taken forward into service design. Review: It will be important to share the draft regulations or service design plans back with people for review of the alignment with co-design process. 6.5.1 Themes As outlined in the Programme structure design themes have been identified, whilst not exclusively the case for all co-design engagement, the Programme will often choose to align a number of policy areas to larger themes, known as ‘design themes.’ This allows for co-design activities to be conducted within the scope of a larger thematic area, with the insights gained then being aligned with the more granular policy areas of scope through analysis sessions.
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PBC Co-design is central to successful delivery and is therefore embedded in the governance structures, as outlined above there is a dedicated co-design assurance group that supports decisions making on co-design on behalf of the PDB. Successful delivery will require effective stakeholder engagement and communication. The Programme will prioritise meaningful, inclusive, and accessible stakeholder communications and engagement. The priority will be to disseminate timely and accurate information and to ensure that the voices of the diverse range of partners and stakeholders with an interest in the NCS are heard, with an emphasis on the centring of the voices of people with lived and living experience of accessing and delivering social care support. The key objective underpinning all NCS programme communications and engagement activity is that; The Programme Strategic Communications and Engagement unit aims to ensure that we communicate and engage with these groups in meaningful and inclusive ways and will support colleagues to do so, ensuring that the voices of our diverse range of partners and stakeholders are heard. Co-design activity will continue and grow over the lifecycle with participants drawn from the Lived Experience Experts Panel and the Stakeholder Register, as well as partnership work with stakeholder partners. 6.6 Building our Communications Channels and Messaging The NCS Programme has developed a communications strategy to support different elements of the Programme. This followed audience insights research in early 2023. The communications strategy and plans are based on evidence and developed in conjunction with stakeholders. The audience for this strategic messaging is internally across the Programme, Scottish Government and externally with stakeholders, people with lived experience and the wider public. This is supported by the Key Stakeholder Reference Group and focused Key Stakeholder Steering Group, both of which include a wide range of stakeholder representatives from across all sectors. Channels in place, include internal newsletter, presentations, online content including blogs and social media, stakeholder newsletter and stakeholder toolkit. Our ‘Voices’ of community health and social care video campaign has been another key channel for shining a light on the diverse living and lived experiences of those accessing and delivering care and their hopes for a future NCS. The Programme will continue to build a strategic and joined up approach to stakeholder engagement. 6.7 Monitoring and Control The Programme has in place monitoring and control processes to support successful delivery, the includes the governance arrangements outlined above and proportionate risk and change control arrangements. People with lived and living experience of community healthcare, social work, and social care services, those delivering services, and the wider public are at the centre of our work in creating a National Care Service for everyone, with equality, dignity, and human rights at its heart.
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PBC 6.7.1 Risk Management The Programme has in place proportionate risk management processes. This includes programme level risk log and supporting processes to ensure its regular and robust management. The Programme’s Risk and Issue Management Strategy sets out the purpose and goals of the risk and issue management framework required within the NCS Programme. This strategy provides risk management guidance to the Programme to ensure the application of a consistent, standardised approach which is in line with the wider risk protocols of the Scottish Government and for the management of issues that arise from them. The approach uses assessments from subject matter experts within the Programme to identify programme risks and to identify and implement the appropriate mitigations. The process also enables scrutiny and discussion of risks, as well as mitigations at the Risk Review Panel (RRP) and facilitates the regular update and consideration of these risks. The RRP is subordinate to the Programme Delivery Board, which is provided with regular reporting of programme level risks and acts as an escalation point for RRP where risks are deemed to require greater intervention by the panel. 6.7.2 Change Control Change Control Strategy is designed to ensure that changes are made at the appropriate level, by the people with the authority to make them. Change Control introduces a robust process for scrutinising changes that are made to key elements of the Programme, such as scope, planning or budget. 6.8 Programme Assurance The Programme is establishing an Assurance process linked to the Governance arrangements. This will include both independent and internal assurance activity. This will include Gateway reviews, Gateway 0 at Programme level with Gateway 2-5 at project level, mandatory digital assurance, and internal audit. In addition, the Programme will engage regularly with Audit Scotland.
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1 NATIONAL CARE SERVICE (SCOTLAND) BILL – UPDATED FINANCIAL MEMORANDUM DECEMBER 2023 1. In line with the request from the Finance and Public Administration Committee in their report published 1 December 2022, this paper provides an update to the Financial Memorandum for the National Care Service (Scotland) Bill, as an annex to the Scottish Government’s response to that report. 2. This version reflects the Bill as Introduced, and the costs that would arise should the Parliament decide not to make any significant changes to the Bill at Stage 2. New text and tracked changes to the text are shown in red to be clear where and what the updates are. Where no changes are shown, the text of this document remains that of the Financial Memorandum submitted with the National Care Service (Scotland) Bill as Introduced on 20 June 2022. Separate papers set out the key changes that the Scottish Government proposes to bring forward, following the agreement made with COSLA on shared accountability, and the anticipated impact of those changes on the costs arising from the Bill. 3. Original tables are shown which can be directly read back to the Financial Memorandum at 20 June 2022. Updated tables are presented below the original tables and now show a ten year period compared to the original five years, due to the longer phasing of Care Boards being established. 4. The Scottish Ministers originally gave a commitment to deliver a National Care Service (NCS) by the end of this Parliament. This assumed that there would be wider agreement on the progression of local structures and that there would be sufficient funding and resources available. In consideration of the current financial position nationally and within the Scottish Government, what is achievable within the current anticipated funding envelope has been reviewed, alongside the effect of the longer time taken for scrutiny of the Bill by Parliament. It is expected that the national level part of the NCS will be established during 2025-26 (as described below, the NCS at national level under the Bill as introduced would be part of the core SG), and again, under the Bill as introduced, NCS local care boards were assumed to go live during 2028- 29. As such, the costs outlined in the tables below have been re-phased across a ten year period from 2022-23 to 2031-32 to account for this and so there are some significant financial moves between this update and the original Financial Memorandum.
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2 INTRODUCTION 5. This Financial Memorandum is structured as follows: From paragraph Background 8 Summary of total costs of the Bill After 23 (Table 1) Establishment of a National Care Service and Care Boards 26 Care boards 47 Health and Social Care Information 66 Right to Breaks from Caring 69 “Anne’s Law” – Visits to or by care home residents 85 Changes to powers and functions of the Care Inspectorate 100 6. Each part will examine the estimated costs for the different sectors involved, including, as appropriate, the Scottish Administration, Local Authorities, Health Boards, other public bodies, businesses and third sector organisations, and individuals. Each part will set out: the best estimates of the administrative, compliance and other costs to which the provisions of the Bill will give rise; the best estimates of the timescales over which the costs and savings are expected to arise, and an indication of the margins of uncertainty in these estimates. 7. The figures set out in this Financial Memorandum represent the Scottish Government’s best estimates of the costs of the activities affected by the provisions of the Bill. These figures are not spending commitments and should not be used as a tool for future budgeting, as costs may be affected by other factors in addition to the changes made by the Bill. Funding for the organisations involved will be negotiated in the usual way taking into account the projected costs of their functions at the time. BACKGROUND 8. The purpose of the National Care Service (Scotland) Bill is to improve the quality and consistency of social services in Scotland. Part 1 gives the Scottish Ministers a duty to promote a comprehensive and integrated care service, and gives them the powers they need to achieve that, including making provision for the establishment of care boards to carry out Ministers’ functions in relation to social care and community
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3 health. Part 1, Chapter 6 gives the Scottish Ministers powers to transfer relevant functions from local authorities or from health boards. “The National Care Service” (NCS) means the Scottish Ministers and care boards working together to deliver those functions. 9. Part 2 of the Bill allows for information sharing and information standards and is intended to underpin the creation of the nationally- consistent, integrated and accessible electronic social care and health record. This will help professionals to support individuals in a more co- ordinated way, and support national and local planning and commissioning. 10. Part 3 makes additional reforms to the delivery and regulation of care. It introduces a right to breaks from unpaid caring, and Anne’s Law, to support people living in care homes to maintain contact with family and friends even in outbreak situations. It makes changes to the powers of the Care Inspectorate, and Health Improvement Scotland. These are all changes that can be implemented to improve the lives of people who access social care support and their carers before the NCS is established. Some of them take the framework approach to allow for further engagement and flexibility; others are more detailed where they address specific points in existing legislation. Framework and Co-design approach 11. It is essential that reforms to social care support must be developed with the people who access that support, including unpaid carers, and with those who provide it. The Scottish Government is committed to engaging with people with experience to co-design the detail of the new system, to finalise new structures and approaches to minimise the historic gap between legislative intent and delivery. For that reason the bill creates a framework for the NCS, but leaves space for more decisions to be made at later stages through co-design with those who have lived experience of the social care system, and flexibility for the service to develop and evolve over time. Some of those future decisions will be implemented through secondary legislation, others will be for policy and practice. 12. As a result of this framework and co-design approach, there are increased uncertainties surrounding the cost estimates, and the timing of those costs. Estimates for a range of possible options have been included in this Financial Memorandum where possible and the costs have been timed to deliver an operational NCS and begin the reform of local delivery by the end of this Parliament. Future decisions about the implementation and phasing of the NCS will take into account rigorous, evidence-based options appraisals, value for money, where benefits and quality are paramount, and the resources available to ensure affordability. Where those decisions are implemented through secondary legislation (under this Bill or through pre-existing powers), financial and regulatory impact assessments will be provided. The Parliament will, therefore, have further opportunities to examine the cost implications of the Scottish Government’s proposed reforms to the social care system.
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4 Other planned reforms 13. The costs set out in this Financial Memorandum reflect community health and social care services as they are currently delivered, and estimates the changes to those costs that will result from the provisions of this Bill. However, the creation of the NCS and other changes made by the Bill are only part of a wider programme of social care reform. Other elements of those reforms, that do not require primary legislation and could go forward irrespective of the Bill, are likely to have an impact on the overall cost and expenditure on community health and social care support during the time period covered by this Financial Memorandum. In order to focus only on the impact of the Bill, the estimates provided here do not include the effect on the NCS of the following Scottish Government commitments: To increase pay and improve terms and conditions for adult social care staff in the third and private sectors, including establishing appropriate channels for workforce and trade union representation To bring Free Personal Nursing Care rates in line with National Care Home Contract rates To remove charging for non-residential care To increase investment in social work services To increase provision of services focusing on early intervention and prevention To invest in data and digital solutions to improve social care support. 14. Overall the Government has committed to increase public investment in social care by 25% over this Parliamentary session (2021- 26). 15. Creation of the NCS will support many of these reforms; for example, it is intended that it will support greater consistency in the provision of services focusing on early intervention and prevention, and in ethical commissioning which will promote Fair Work standards for staff. However, these are policy decisions to be made or sustained under the new framework, not necessary consequences of the Bill provisions. Economic benefits of establishing the NCS 16. The purpose of creating the NCS is to improve the delivery of community health and social services. Social services have a significant economic impact, and therefore investments in improving their quality and consistency can have a positive effect on the economy.
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4 17. Making Scottish Ministers responsible for social care with local care boards commissioning community health and social care together enables:
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5 the development of a system based on and driven by shared principles which enshrine human rights and person-centred care with opportunities for the voice of lived experience to be embedded in all levels of decision making; opportunities to build on health and social care integration and to bring together different services to with a focus on outcomes and to help smooth transitions for people - noting that there needs to be further evidence gathering to see if children’s services and justice social work should be brought in scope of the NCS; strengthening of ethical commissioning of care; the development of clear and consistent standards and to support the delivery of high quality and improve consistency; and market oversight to promote the financial sustainability of social care providers and, where necessary inform service design and market shaping to help ensure the market for social care as a whole remains vibrant and stable which will ensure continuity of quality social care provision. 18. This in turn, is expected to lead to the benefits for people and for Scotland’s wider society and economy through improved community health and social care support for people those who need it and their families, with people being able to access services when they are needed. It is also expected to lead to improved experiences for those who work in social services through strengthening fair work in the sector and improved support and recognition for social work and social care. This will help with workforce retention and recruitment. 19. In 2020 social services directly employed 209,690 people, approximately 8% of the Scottish workforce, with a whole time equivalent (WTE) of 159,2601. A 2018 report commissioned by the Scottish Social Services Council (SSSC)2 quantified the direct, indirect and induced contributions that the adult social care sector makes to the Scottish economy: The direct economic value of social care activity is estimated at £2.3 billion - £2.6 billion (dependent on measurement method used). The indirect economic value of goods and services in the sector’s supply chain is estimated at £0.5 billion - £0.6 billion. The induced impact associated with goods and services bought by those directly or indirectly employed by the sector are estimated at £0.7 billion. The indirect and induced impacts resulted in an additional 50,800 jobs. 1 Scottish Social Service Sector: Report on 2020 Workforce Data | Scottish Social Services Workforce Data (sssc.uk.com)
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5 2 The Economic Value of Adult Social Care (https://data.sssc.uk.com/data-news/15-announcements/175-the-economic-value-of-adult-social- care#:~:text=The%20adult%20social%20care%20sector,and%20Wales%20published%20similar%20reports.)
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6 The total estimated economic value of the sector is therefore in the range £3.5 billion - £3.9 billion (excluding harder to quantify catalytic effects). 20. A report by the Women’s Budget Group (WBG) of the International Trade Union Congress (ITUC) identified that for every £1 spent on social care, more than £2 is generated in other sectors3. The same group4 estimates that the majority of new jobs created by investment in social care will be taken by women. Investment in social care can therefore help to reduce the gender pay gap. The large reach of the sector also has an important contribution to make to tackling inequalities, including child poverty, and meeting Scotland’s climate change and sustainability goals through more efficient use of estates, travel, and waste. 21. The social care sector has an important role in supporting local economies across the country. Social care employment and investment is present in every area of Scotland; in areas of economic disadvantage the sector can be a critical employer, particularly in areas with high youth unemployment. The sector is also an important procurer and purchaser of goods and services and this can have important local benefits. The sector can direct spending towards local small businesses, voluntary, and community organisations rather than national corporations, and can also lead through setting importance on quality non-financial standards in procurement processes. 22. Investment in social care support generates social value in terms of people’s emotional wellbeing and better health. A study of the Independent Living Fund in Northern Ireland estimates that every £1 spent generates £11 of social value5. Both for people who use social care support, and equally importantly for unpaid carers, the availability of high quality adult social care support can help people to engage in and remain in education and also to enter and remain in work. 23. Improving social care support, particularly increasing early intervention and prevention and supporting unpaid carers to protect their health and wellbeing, also reduces costs which would otherwise fall on other parts of the public sector. This can include unplanned hospital admissions, additional residential care needs, and family breakdown. It is difficult to estimate the size of these wider savings and benefits in total but the Scottish Government expects these to be considerable. Some estimates relating to the benefits of improving support for unpaid carers are provided in paragraphs 72-75. 3 Investing in the Care Economy - Womens Budget Group (wbg.org.uk)
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6 4 Investing in the Care Economy - Womens Budget Group (wbg.org.uk) 5 44188-ILF-NI-Impact-Evaluation-Report.pdf
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7 SUMMARY OF ESTIMATED COSTS OF THE BILL Table 1: Total estimated costs of Bill provisions Note: in all tables, there may be small discrepancies in totals due to rounding As per published Financial Memorandum on 20 June 2022 Sector 2022-23 2023-24 2024-25 2025-26 2026-27 £ millions £ millions £ millions £ millions £ millions Total estimated costs of Bill provisions 24-36 63-95 84-126 232-477 241-527 Establishment and running of NCS national organisation – table 6 Scottish Administration 24-36 60 - 90 72 - 108 92 - 138 83 - 124 Establishment and running of care boards – table 7 Scottish Administration 0 4 - 6 12 - 18 Care boards 132 -326 142 - 376 Total NCS costs 24-36 63 - 95 84 - 126 216 – 452 224 - 464 216 - 488 225 - 500 Right to breaks from caring* - table 11 Care Boards - - - 8 – 13 16 – 27 Anne’s Law – table 14 Care Inspectorate 0.186 0.09 0 0 0
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8 *Note that tables 10-14 show costs to 2034-35 Note the Finance and Public Administration Committee were previously notified6 that there is a mathematical error for 2025/26 and 2026/27 in the above table 7 extract. Total NCS costs for these years should be £224m - £464m, and £225m to £500m respectively and so have been updated. Updated as per December 2023 Sector 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £m £m £m £m £m £m £m £m £m £m Total estimated costs of Bill provisions 13 11 - 13 13 - 17 32 - 46 45 - 64 64 - 115 105 - 353 158 - 438 210 - 524 229 - 609 Establishment and running of NCS at national level – table 6 Scottish Administration * 13 11 - 13 13 - 17 19 - 27 18 - 26 17 - 26 17 - 26 18 - 27 18 - 28 18 - 28 Establishment and running of care boards – table 7 Scottish Administration 0 0 0 0 0 7 - 30 0 0 0 0 Care boards 0 0 0 0 0 0 33 - 247 70 - 309 106 - 371 109 - 433 Total 0 0 0 0 0 7 - 30 33 - 247 70 - 309 106 - 371 109 - 433 Total NCS costs 13 11 - 13 13 - 17 19 - 27 18 - 26 24 - 56 50 - 273 88 – 336 124 – 399 127 - 461 6 Minister for Mental Wellbeing and Social Care (parliament.scot)
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9 Right to breaks from caring - table 11 Social Care / Care Boards 0 - 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 Anne’s Law – table 14 Care Inspectorate 0.19 0.09 0.05 0 0 0 0 0 0 0 Total right to breaks & Anne's law 0 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 *Note that costs in 2022-23 are based on actuals, 2023-24 are forecast outturn. Variance 2022-23 23-24 24-25 25-26 26-27 £m £m £m £m £m Scottish Administration -11 – -23 -49 – -77 -59 – -91 -73 – -111 -65 - -98 Care Boards 0 -4 – -6 -12 – -18 -132 - -326 -142 - -376 Right to Breaks & Anne’s law 0 0 0 5 – 6 11 Reasons for Variances: The most significant change is driven by the movement as to when NCS local care boards will go live. The go live date has been moved to 2028-29 from the original estimate of 2025-26. See table 7 for a further breakdown and explanation. Due to a clearer understanding of the requirements in the set-up of the NCS at National level, obtained through the co- design workshops and engagement with people with lived experience, the NHS and COSLA, the NCS programme has reprioritised and rephased various workstreams to reflect the new understanding. Ensuring value for money has been a focus of these considerations. This has led to a significantly reduced financial outlay for the Scottish Administration in the assumed set up phase under the Bill as introduced compared with the original FM. Tables 3-6 provide further detail on the changes that have driven this reduction. In summary, they relate to a far more streamlined staffing complement with reduced agency involvement alongside the reduction in external procurement of services and the utilisation of existing Scottish Government systems, where previously there had been provision for new systems.
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10 Inflationary assumptions have been revised in light of more recent data, see table 1A for full details on the changes made to the inflationary assumptions. To summarise, the changes are variable but from 2023-24 onwards the picture is one of reduced inflationary impact. INFLATION 24. Following the significant volatility in the rate of inflation throughout the course of 2022-23 and 2023-24 the inflation estimates used in the original Financial Memorandum have been revised. This is part of ongoing financial modelling work to track changes to inflation and a range of other assumptions. 25. The Office for Budget Responsibility (OBR) and Scottish Fiscal Commission (SFC) forecasts have been assessed, and will be used as the basis for inflation going forward. Source documents can be found here: Where can I find your latest forecasts? - Office for Budget Responsibility (obr.uk) – link to document under 1.7 supplementary economy tables / Scotland’s Economic and Fiscal Forecasts – Scottish Fiscal Commission – May 2023 Report The projected figures extend to 2027/28. Given the extended timeframe due to the assumed rephasing of Care Boards going live, the Bank of England target inflationary figure of 2% has been applied from 2028-29 onwards. The below rates have been used for all future year non pay cost calculations. This impacts costs throughout the Financial Memorandum. Table 1A: Inflation (was not numbered in finance memo before) As per published Financial Memorandum on 20 June 2022 2020-21 2021-22 2022-23 2023-24 2024-25 2025-26 2026-27 2.3% 2.5% 6.2% 6.2% 2.0% 2.0% 2.0% Updated as per December 2023 2020-21 2021-22 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 0.6% 4.0% 10.0% 4.1% 0.6% 0% 0.8% 1.7% 2.0% 2.0% 2.0% 2.0%
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11 Pay Uplifts In line with revising non pay inflation as set out above, assumptions on pay uplifts have also been revised. Scottish Government pay awards were analysed between 2015-2016 and 2024-2025, 2024-25 was included following the agreement on the multi year pay deal between SG and its employees, but no direct correlation was found between the average pay award and the CPI inflationary figures across this period. The average pay increase over this period was 2.8%, with 2023-24 excluded from the average as this was an outlier due to the unprecedented impact of inflation. The 2.8% average figure has therefore been applied to all staffs future forecasts from 2025-26 onwards, the exception being direct care workers as set out below, to ensure consistency. Care workers pay is based on the National Living Wage commitments from 2021-22 to 2023-24 while Auxiliary staff are based on the Real Living Wage. The staff in scope for transfer (under the Bill as introduced) are Local Government employed staff. We are aware their pay will not track directly to the National Living Wage / Real Living Wage but this provides a standard minimum assumption to work from. Pay inflation of 5% has been applied to this group to conform with historical averages and based on the ongoing Fair Work commitments. ESTABLISHMENT OF A NATIONAL CARE SERVICE AND CARE BOARDS Current costs of social care support and community health 26. Part 1, Chapter 6 of the Bill provides powers to allow for the transfer of social services functions from local authorities to the Scottish Ministers or to care boards. The functions covered by these powers include adult social care and social work, children’s social work and social care, and justice social work. In relation to services for children and justice, further work will be undertaken with stakeholders to consider the risks and opportunities, and to rigorously assess the costs and benefits, before decisions are made about implementing the transfer and how it might be phased. Section 30 makes provision requiring the Scottish Ministers to consult publicly about any proposed transfer relating to children’s or justice services before regulations are brought forward. A summary of the process and responses received to the consultation must be laid before Parliament at the same time as the draft regulations. Ministers will also have powers to transfer functions from health boards to the new care boards, and to delegate their own health functions as NCS functions, in order to maintain the integration of community health and social care functions. 27. The figures for the costs of delivering services which may transfer, set out in table 2, provide a range of estimates in which the lower figure would cover only the transfer of adult social care, and the upper figure would include the transfer of all the services mentioned in paragraph 24 above. These are not additional costs to the system therefore have not been included in table 1.
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12 28. Care boards will have the statutory duty to carry out the transferred functions in their local area, and will hold the funding for them. Care boards will plan and commission local services. Social work and social care support will continue to be delivered by a range of public, private and third sector partners. For services currently provided in-house by local authorities, that may continue under a procurement arrangement with the care board, or the care board may take over direct delivery, with staff transferring to the care board. These will be decisions to be taken locally as the care boards are established, following careful options appraisals. It is expected that health services will continue to be delivered by the NHS, as commissioned by the care board. 29. It is anticipated that the Scottish Ministers may transfer some functions, at least in part, to themselves, and the NCS at national level may plan, commission and procure social care services for people with complex and specialist needs across Scotland. Further decisions will need to be taken, in discussion with those accessing and providing such services, about which services may be treated in this way, before any estimate can be made of what proportion of costs they will represent. 30. Table 2 sets out the approximate current and projected costs of the services that could be transferred to care boards and to the Scottish Ministers. In terms of the total costs to the public purse, it is assumed the transfer of services itself has no effect: the costs of providing these services will simply transfer from local authorities and health boards to the NCS. Any policy decisions between now and the date of transfer would be taken into account in rebasing the transfer value. Subsequent sections of this Financial Memorandum set out the additional costs relating to setting up the new bodies, and to issues such as aligning terms and conditions for staff transferring from different organisations. 31. The transfer of functions may take place immediately on establishment of care boards in 2025-26 2028-29, or may be phased with different functions transferring gradually over a number of years. A phased approach may result in a period of double running costs or transfer costs in addition to the costs set out below, these would be anticipated to be applicable to back office functions only. Decisions on the timing of transfers will be subject to rigorous readiness and financial assessment to ensure value for money and affordability, as well as ensuring there is no disruption to the provision of support to people. 32. The costs set out in table 2 are based on a range of caveats and assumptions as follows: Figures are presented in real terms, based on the most recently available full data collection. The Local Finance Return (LFR) data for Local Authorities is from 2021-22 while the NHS cost book data is taken from 2019-20. This is due to removing the outlier COVID year data and many NHS Boards not completing full returns in the subsequent years as a result of ongoing COVID pressures. Public Health Scotland (PHS) note that a full data collection is expected for the 2022- 23 data but this is currently still under development (source: Scottish health service costs - High-level costs summary 2021 to 2022 - Scottish health service costs - Publications - Public Health Scotland)
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13 Local government finance statistics - gov.scot (www.gov.scot) based on Local Financial Return on Social Work (LFR03) Scottish health service costs - CostsBook 2020 (April 2019 to March 2020) - Public Health Scotland. They do not account for any impact of Covid on services, to avoid extrapolating forward any non-recurring expenditure. Figures given here are illustrative to show a scale of the services in scope. Figures represent the Scotland-wide costs of functions which are expected to be transferred to care boards. Currently, the range of functions delegated to Integration Authorities is different in each area, therefore the costs of future NCS functions cannot be extracted from integration budgets. The LFR03 captures actual total expenditure by local authorities on Social Work services as reported in their published annual accounts and is therefore the most accurate data on costs available at this time. This will not necessarily agree with specific funding allocations, such as for justice social work services, as local authorities will utilise additional resources to meet expenditure commitments (Block grant, Council Tax and Non-Domestic Rates). The exact list of health functions that may be transferred to care boards is yet to be determined, therefore the costs of health functions are indicative at this stage. These figures have been projected forward using inflation (see table 1A above) plus a standard 3% increase on all years and services to show growth in activity and any pressures above inflation e.g. pay, prescribing and energy prices. This is net of any savings made. 33. Work will continue through the period of developing the NCS to understand demand and activity trends, as well as the exact services to be transferred, to provide robust cost forecasts for the NCS and inform future budget and funding negotiations. Figures given here are illustrative to show a scale of the services in scope.
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14 Table 2: Costs of providing services that could be transferred to care boards As per published Financial Memorandum on 20 June 2022 Cost Category 2019- 20 2020- 20 2021- 22 2022- 23 2023- 24 2024- 25 2025- 26 2026- 27 £m £m £m £m £m £m £m £m Social Care services Adult social care 3,517 3,659 3,844 4,205 4,600 4,833 5,077 5,334 Children’s and families 992 1032 1084 1186 1298 1363 1432 1505 Justice social work 137 143 150 164 180 189 198 208 Service Strategy 52 54 57 63 68 72 76 79 Total 4,699 4,889 5,136 5,618 6,146 6,457 6,783 7,127 Community Health services Primary care 2,690 2,799 2,941 3,217 3,518 3,696 3,884 4,080 Community Health 3,135 3,261 3,427 3,748 4,100 4,307 4,525 4,754 Mental health services (apart from inpatient and state hospital) 70 73 76 84 92 96 101 106 Total 5,895 6,133 6,444 7,048 7,710 8,100 8,510 8,940
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15 Updated as per December 2023: Cost Category 2019- 20 2020- 21 2021- 22 2022- 23 2023- 24 2024- 25 2025- 26 2026- 27 2027- 28 2028- 29 2029- 30 2030- 31 2031- 32 £m £m £m £m £m £m £m £m £m £m £m £m £m Social Care services Adult social care £3,517 £3,644 £3,987 £4,513 £4,842 £5,018 £5,168 £5,367 £5,624 £5,909 £6,208 £6,522 £6,852 Children’s and families £992 £1,028 £1,038 £1,175 £1,261 £1,307 £1,346 £1,398 £1,465 £1,539 £1,617 £1,698 £1,784 Justice social work £137 £142 £149 £169 £181 £188 £194 £201 £211 £221 £233 £244 £257 Service Strategy £52 £54 £84 £95 £102 £105 £109 £113 £118 £124 £130 £137 £144 Total £4,699 £4,869 £5,258 £5,952 £6,387 £6,619 £6,816 £7,079 £7,418 £7,793 £8,188 £8,602 £9,037 Community Health services Primary care £2,690 £2,787 £2,986 £3,380 £3,626 £3,758 £3,870 £4,019 £4,212 £4,425 £4,649 £4,884 £5,131 Community Health £3,135 £3,248 £3,479 £3,938 £4,226 £4,379 £4,509 £4,684 £4,908 £5,156 £5,417 £5,691 £5,979 Mental health services (apart from inpatient and state hospital) £70 £73 £78 £88 £94 £98 £101 £105 £110 £115 £121 £127 £133 Total £5,895 £6,108 £6,542 £7,406 £7,947 £8,235 £8,480 £8,808 £9,230 £9,697 £10,187 £10,703 £11,244 Reasons for Variances: Changes to costs of service provision that could be transferred to care boards is due to inflationary adjustments and the inclusion of 2021/22 Local Finance Return data, previously 2019/20 (see table 1A for full details on the changes made to the inflationary assumptions). We are aware much of the costs above will be driven by the costs of staff who deliver care services, however there is no available data to disaggregate pay and non-pay cost drivers. As noted in the original Financial Memorandum an additional 3% growth rate has also been applied to these in addition to inflation to cover any additional pay or demographic increases.
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16 The source for table 2 remains published information from the NHS Cost book and Local Government Finance Returns with all other assumptions set out in the original Financial Memorandum remaining in place. Inflation has been applied as per table 1A with an additional 3% growth rate in our assumption. Establishment of the National Care Service 34. Section 35 of the Bill sets out that “the National Care Service” means local care boards and the Scottish Ministers exercising their functions in relation to social services. Under the Bill as introduced a At national level there would will not be a new public body; the Scottish Ministers’ new responsibilities for social work and social care support would will be managed and overseen by civil servants directly accountable to Scottish Ministers, in the same way that the National Health Service is managed by the Health Directorates of the Scottish Government. This would will include the proposed National Social Work Agency, which would will be established as a unit within the NCS to provide national leadership and support for the social work profession. 35. Staff currently engaged in policy development and oversight of public bodies relating to social services would will transition to become part of the NCS structure. However the increased responsibilities will require additional staff to be recruited, with associated costs such as premises, equipment and IT. Those increased responsibilities would include: providing leadership, oversight, and accountability for community health, social work and social care support, including by providing strategic direction and planning at the national and regional levels creating, managing and promoting national community health and social services policies, setting national standards and developing practice standards, models and guidance to improve access to care creating and overseeing a framework for ethical commissioning, including Fair Work requirements, and carry out workforce planning developing and maintaining a national complaints system design and delivery of the integrated social care and health record and NCS digital services. National costs – establishment phase 36. The Scottish Government is committed to establishing the NCS by the end of this Parliamentary term, i.e., in financial year 2025-26. Costs for an additional year have been provided to allow for the transition to steady operating costs. Work is ongoing to ensure the NCS can go live in 2025-26. This includes policy development and co-design, Programme and Project Management (PPM), recruitment costs, financial
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17 forecasting, data and digital discovery work and workforce planning. Costs include staff and non-staff costs with a transition into running costs once the a NCS is fully established in 2025-26. These costs cannot therefore be thought of as ‘one off’ set up costs, they are the foundation of an NCS, with the staff and skills transferring into the running of the organisation. This allows investment into public sector staff, to upskill on data and digital capabilities, PPM methodologies and financial qualifications. 37. The staff set up costs shown in table 3 are based on a headcount profile currently assumed for the length of the establishment phase, as above these staff would then in the main move to the running cost of the NCS, hence this drops to 0 in 2026-27. It is expected a portion of the staff costs will be in the data and digital space, some of which will be shorter term contractors with specific skills for set periods of time. This causes a spike in the latter part of 2023-24 based on current phasing of programmes. 38. Current assumptions of staff headcount and costs have been based on actual staff numbers in 2022-23 and 2023-24 with management and policy estimates of resource need for the various elements of the programme in the longer term. As the scope, scale and timeline for the NCS is still to be fully developed through co-design and evidence-based options appraisal, this headcount profile is likely to change, potentially significantly, as more detail is known. Table 3: NCS National establishment phase headcount and staff costs As per published Financial Memorandum on 20 June 2022: 2022-23 2023-24 2024-25 2025-26 2026-27 Headcount 200 - 300 440 - 660 440 - 660 60 - 90 0 Staff costs (£m) 18 - 27 47 - 71 48 - 72 5 - 7 0 Updated as per December 2023: 2022-23 2023-24 2024-25 2025-26 2026-27 Headcount 183 204 - 249 222 – 271 240 – 293 0 Staff costs (£m) 10 10 - 12 11 – 14 7 – 8 0 Variance (£m) -8 - -17 -37 – -59 -37 - -58 2 - 1 0 * The staff costs in 2025-26 represents 6 months of costs as during 2025-26 it is anticipated the NCS will go live. As such staff will migrate to the running phase as set out in table 6
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18 Underlying Calculation Assumptions: The estimate of staffing is taken from current staffing figures and costs, alongside expected requirements for new posts, tied to delivery timelines. The updated figures anticipate a gradual increase in staff as the Programme approaches the launch date in 2025-26, but this is smaller than previously estimated. The costs in 2025-26 represent partial year costs as staff migrate across to working in the running of NCS National. The running phase 2025-26 costs of those staff that move are reflected in table 6 below. Reasons for Variances: Reductions in headcount numbers and therefore staff costs are due to a more fully developed understanding of the requirements since the Bill was introduced, as well as the rephasing and reprioritisation of workstreams to ensure the most effective use of resources. It is anticipated that the programme will continue to run with a more streamlined staffing base compared with the original Financial Memorandum through the development and subsequent operation of the NCS as a result of this. The programme will increase the skills of existing staff and limit the number of external contractors further reducing the incurred and anticipated staffing cost. Headcount drops to 0 in 2026-27 as staff are assumed to transfer to the NCS National running costs. The ratio of staff costs to headcount has also reduced. This is partly as there is a lower ratio of contractor staff, who carry a higher wage, compared to previously forecast costs, coupled with a more robust ongoing staffing forecast based on actual staff numbers in 2022-23 and 2023-24. For future years there remains an element of contingency for areas that are still to be developed as part of the codesign phase and where additional staff have been included. 39. Non-staff costs relate to areas such as IT systems, consultancy costs, co-design and engagement work, external grants to partner organisations and operational expenses and training and premises costs. This is estimated in table 4. Table 4: NCS National establishment phase non-staff costs As per published Financial Memorandum on 20 June 2022: 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Systems and IT 0 0 - 1 9 - 13 2 - 4 0 Training and other staff costs 0 2 2 0 0
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19 Premises costs 0 1 2 - 4 2 0 Third party advice (legal - consulting) 6 - 9 10 - 14 10 - 14 2 0 Total 6 - 9 13 - 19 22 - 34 6 - 8 0 Updated as per December 2023: 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Systems & IT 0 0 0 0 - 1 0 - 1 Staff Related 0 0 0 0 0 Engagement 1 0 0 0 - 1 0 Grants 0 0 0 0 0 Co-Design 0 0 - 1 0 - 1 1 0 Research & External Advice 2 0 1 1 0 Total 3 1 2 - 3 2 - 4 1 Variance -3 - -6 -12 - -18 -20 - -31 -4 - -4 1 – 1 Note – The costs above show a significant number of £0s. While we expect some costs, these fall below the £500k threshold to be rounded up. The average costs for the individual lines are between £300k - £600k per annum with the exception of staff related which is on average £120k. Underlying Calculation Assumptions: The costs within the setup phase have been based on the current breakdown of expenditure incurred within the NCS programme as well as a programme wide assessment of the anticipated requirements aligned to planned delivery timescales. Costs have been inflated forward using the revised inflationary rates, see table 1A for full details. Cost range – The lower limit is based on reducing costs from 2023-24 onwards to 80% to reflect any underspend against budget / anticipated spend values. The upper limit is based on increasing the costs to 120% to reflect any unforeseen expenditure or cost over runs in the project work
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20 Reasons for Variances: Inflation assumptions have changed, see table 1A for full details. 2022-23 costs are based on actuals as per the end of financial year. These are lower than the original Financial Memorandum as a result of government wide savings exercises following the Emergency Budget Review in November 2022. 2023-24 through to 2025-26 costs are significantly lower than previously estimated due to a change in nature of the programme and a more developed understanding of programme requirements. The internal staff skillset will be utilised in favour of externally contracted services. NCS National is assumed to share IT and back office services with SG and therefore Systems and IT costs have been reduced along with premises as NCS National will utilise existing Scottish Government sites. The spend categories have been amended to be more reflective of the programme reporting framework and better highlight how money has been and is planned to be spent. National ongoing running costs 40. The Bill as introduced provides for the Scottish Ministers to become responsible for social work and social care support for adults, for children, and relating to the justice system. As set out in the policy memorandum, further work is required to consider the risks and opportunities, costs and benefits of the transfer of services for children and justice, and the transfer may be phased over a longer period. However, since no decisions have yet been taken on such phasing, the figures in tables 5 and 6 assume that the NCS would will take on the full range of services from the start. As the Scottish Ministers already have responsibility for primary care and community health, and teams in the Scottish Government managing those areas, it is assumed there will be no change in costs relating to that work 41. Running costs for the NCS have been estimated based on this full range of functions. This includes staff costs across various different teams, the majority being the existing staff from the establishment phase. Total headcount is expected to grow to the region of 500 – 700 people, though not to the previous estimate of 500 – 700 people, which is in line with other large areas within government, such as Social Security as the programme resource requirement has been reviewed and streamlined. These are not all additional posts compared to current headcount profile, and as per the headcount profile for the establishment phase, the staff base for the NCS will be built over the next 3-4 2-3 years. 42. The estimated set up and running costs have been established by assessment of current programme progress and
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20 requirements alongside the anticipated expansion as the programme moves from set up to running and what that will involve and the NCS National requirements. comparison to the existing costs of national management of the National Health Service and other large scale transformation programmes in the public sector, such as the creation of Social Security Scotland.
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21 43. The range of functions has been considered that would need to be developed to support the NCS – quality improvement, performance and delivery, workforce planning, policy development, finance (for example) and how these might be delivered most efficiently. The costs of national management of the NHS have been referenced while considering the drive for public sector reform and increased efficiency. 44. Non staff costs are set out in table 5 below. As above, these are high level ranges based on current estimates, and further work is required to refine these estimates. Table 5: NCS National running costs - non-staff costs As per published Financial Memorandum on 20 June 2022 2022/23 2023/24 2024/25 2025/26 2026/27 £m £m £m £m £m Systems and IT 0 0 2 11-16 10-16 Training and other staff costs 0 0 0 3-5 3-5 Premises costs 0 0 0 5-7 5-7 Third part advice (legal / consulting) 0 0 0 4-6 4-6 Total 0 0 2 23-34 22-34 Updated as per December 2023: 2022-23 2023-24 2024-25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 £m £m £m £m £m £m £m £m £m £m Systems & IT 0 0 0 0 - 1 0 - 1 0 - 1 0 - 1 0 - 1 0 - 1 0 - 1 Staff Related 0 0 0 0 0 0 0 0 0 0 Engagement 0 0 0 1 1 1 1 1 1 1 Grants 0 0 0 1 - 2 1 - 2 1 – 2 1 – 2 1 – 2 1 – 2 1 - 2 Co-Design 0 0 0 0 - 1 0 - 1 0 - 1 1 1 1 1 Research & External Advice 0 0 0 0 0 0 0 0 0 0 Total 0 0 0 3 - 5 3 - 5 3 – 5 3 – 5 3 – 5 3 – 5 3 - 5
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21 Variance 0 0 2 -20 - -29 -19 - -29 No figures for comparison
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22 Note – As above the £0 notation has been used to signify costs below the £500k threshold but above £0. There are no costs incurred prior to 2025-26 as these all sit in the set up phase. Staff related costs average £120k while Research & External Advice average £320k per annum Underlying calculation assumptions: The costs identified within the running phase of the NCS have been reassessed. It is assumed that the NCS National, under the Bill as introduced would exist within Core Scottish Government and as such will be able to utilise existing premises, IT systems and legal services. The costs of running a complaints system have been evaluated based on the desired approach of a web hosted service. There is an expectation that the grant funding to partner organisations will increase to enable them to deliver key services while co-design will become an ingrained part of the ongoing improvement of the NCS. Cost ranges – As with the set up phase the costs are reduced to a lower limit of 80% to reflect the inherent uncertainty in requirements with an upper limit of 120% Reasons for Variances: Inflation assumptions have changed, see table 1A for full details. Certain non-staff elements have been substantially reduced due to a clearer understanding of how the NCS will function within core Scottish Government. The assumed costs around systems, e.g new payroll and HR systems have been removed and these contributed a large cost to the overall position. The digital costs associated with running a complaints system, based on current design analysis, are significantly reduced as well. It is anticipated existing premises will be used thereby removing the need for another large additional cost. The figure set aside for consulting and legal is significantly reduced as existing Scottish Government legal services will be utilised while external procurement of services has been reassessed with a focus on more in house provision to better manage the use of available resources on a recurrent basis and deliver value for money. Non-Staff costs have been re-categorised to better align with programme developments and to provide more clarity and relevance in the relation to non-staff spend against the revised forecasting categories. 45. All the costs of the national management of the NCS will fall to the Scottish Administration.
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23 National Social Work Agency 46. The Scottish Government is committed to establishing a National Social Work Agency, to support and provide national leadership to the social work profession. This would be part of the NCS national management. It is currently estimated that this will contribute costs of £8-121- 2 million in additional staffing annually, which are included in the figures in table 6. The NSWA will support and invest in the social work profession, enabling social workers to work with people to transform their lives and implement rights-based practice as part of the overall objectives on the NCS. Table 6: Costs for NCS National (Costs on the Scottish Administration) As per published Financial Memorandum on 20 June 2022 Cost Category 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Establishment phase Staff costs 18-27 47-71 48-72 5-7 0 Non-staff costs 6-9 13-19 22-34 6-8 0 Totals 24-36 60-90 70-106 10-16 0 Ongoing running costs Staff costs 0 0 0 59-88 60-91 Non staff costs 0 0 2 23-34 22-34 Totals 0 0 2 82 - 122 83 - 124 Overall Total 24-36 60-90 72-108 92-138 83-124
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24 Updated as per December 2023 Cost Category 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £m £m £m £m £m £m £m £m £m £m Establishment Staff 10 10 - 12 11 – 14 7 – 8 0 0 0 0 0 0 Non-Staff 3 1 2 - 3 2 - 4 1 0 0 0 0 0 Total Establishment 13 11 - 13 13 – 17 9 – 12 1 0 0 0 0 0 Running Staff 0 0 0 7 – 10 14 – 20 14 – 21 14 – 21 15 – 22 15 – 23 15 – 23 Non-Staff 0 0 0 3 - 5 3 - 5 3 – 5 3 – 5 3 – 5 3 – 5 3 - 5 Total Running 0 0 0 10 – 15 17 – 25 17 – 26 17 – 26 18 – 27 18 – 28 18 -28 Total NCS National 13 11 - 13 13 – 17 19 – 27 18 – 26 17 – 26 17 – 26 18 – 27 18 – 28 18 – 28 Variance -11 – -23 -49 - -77 -59 – -91 -73 - -111 -65 – -98 No figures for comparison Underlying calculation assumptions: The assumptions outlined below tables 4 and 5 apply to this summary table. The one additional item is the basis for calculating the costs of the running phase staffing. Currently it is anticipated that the majority of staff will migrate from current Scottish Government functions into NCS National. There will of course be those posts that are no longer required and they have been removed, as well as the creation of specific functions that will be expected to go live with the National launch, such as the running of a complaints system. The staff associated with these functions have therefore been included. Reasons for Variances: Inflation assumptions have changed, see table 1A for full details
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25 The most significant reduction evidenced above is in relation to the ongoing staffing requirement and cost. Previously the estimate had been based on assessing the current health directorate spend and attributing a similar cost profile. However, following development in the understanding of the needs of the NCS and assessing opportunities to utilise existing staff and the changing of existing roles, the staff numbers have been streamlined to ensure the NCS delivers value for money yet is flexible enough to meet the challenges faced. The reduction in assumed premium contractor costs in favour of upskilling current staff to provide in house provision is also a contributing factor. The previous assessment of reductions in tables 3,4 and 5 apply to this summary as well. See Table 3 for further breakdown of variances for establishment phase staff costs, and Table 4 for establishment phase non-staff costs. For breakdown of ongoing running non-staff costs variances please see Table 5. Care Boards 47. The Bill gives the Scottish Ministers powers to establish care boards, which are expected to carry out the delivery functions of the NCS and replace the current Integrated Joint Boards (creating an additional body in Highland). Care boards will be accountable to the Scottish Ministers and directly funded by them, and they will employ their own staff. Summary costs for these boards are set out in table 7. Table 7: Summary costs of establishment and running costs of care boards As per published Financial Memorandum 20 June 2022 Sector 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Scottish Administration 0 4 - 6 12 - 18 0 0 Care Boards 0 0 0 132 - 326 142-376
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26 Updated as per December 2023: Sector 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £m £m £m £m £m £m £m £m £m £m Scottish Administration 0 0 0 0 0 7 - 30 0 0 0 0 Care Boards 0 0 0 0 0 0 - 0 33 - 247 70 - 309 106 - 371 109 - 433 Due to the significant change in phasing the variance table has been excluded. Underlying Assumptions: These will be set out under the detail tables 8A and 8B as will the basis for the ranges. It is assumed Care Boards will go live in 2028-29. The costs shown in 2027-28 are the preparatory costs to enable launch. The range is based on either a full roll out of Care Boards at the upper end or a phased introduction at the lower end. Reasons for Variances: Inflation assumptions have changed, see table 1A for full details Rephasing of the Care Board inception date to 2028/29 Revision of estimates for running costs and premises/IT (further detail beneath tables 8A and 8B). 48. Section 4 gives the Scottish Ministers power to determine the number of local care boards and the areas they will cover. Decisions on the number of care boards will require rigorous assessment to ensure value for money, while also considering the best approach to ensure services are designed to meet local needs and circumstances. While the number of local care boards has yet to be decided, the figures in table 7 assume at the top end of the range there will be 3231, one for each Integration Joint Board. 49. The Scottish Ministers will also have powers to create special care boards, which could provide central functions in a similar way to the Special Health Boards. Any decisions to create such special care boards would take account of the costs of setting up a new board balanced against the benefits and any savings to be gained from providing central services. The cost of creating any special boards, should they be formed, will be calculated based on the function and size of the board. Of the current eight Special Health Boards, in 2019/202022-23 their resource allocation share budgets ranged from £18 30 million - £425 492 million.
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27 50. Set up costs such as recruiting board members and acquiring premises prior to establishment of the boards will fall to the Scottish Administration, while ongoing running costs will be allocated to the boards themselves as public bodies. The figures in table 7 include assumed efficiencies from incorporating support services that already exist across the health boards and local authorities, and from the abolition of Integration Joint Boards, which is set against the additional costs of the new boards. The range of costs which have been offset as assumed to already exist are between £25 27 - £40 45 million per year, inflated to 2028-29 costs when Care Boards are due to go live. 51. The timing and phasing of establishing care boards and transferring functions to them will be subject to further discussion through the co-design process and the production of business cases. These will need to consider local tests of change, implementation plans tailored to individual areas and a delivery readiness assessment to ensure no detriment to services while change takes place. The top end of the range of costs in table 7 is based on all care boards having their first year of operation in 2025-262028-29, and assuming that all social workers and care workers will transfer in a phased approach to the NCS. The lower end reflects the possibility that decisions may be taken to start the transfer in a small number of areas, building up over time, to allow appropriate planning, consultation and impact assessment with no staff transferring across. 52. The core management costs of care boards social care staff cost is shown in table 8A while the management costs of care boards are shown in table 8B and will include the following. As noted above, these are all high-level estimates which will be refined as proposals are further developed through the co-design and options appraisal process. Governance and Executive Team – the Bill gives the Scottish Ministers powers to determine in secondary legislation how many members each care board must have and how they provide representation for people with experience of accessing support, workforce and service providers, carers, and partner organisations. Premises and digital set up – high level assumptions are included on costs for digital and premises set up, assuming staff would need digital devices, software licences and access to systems, existing and potentially new. As Integration Joint Boards currently use premises from either the local authority or the health board, it is assumed there will be some need for additional office space, although the current premises will then be freed up for alternative use. Further work will be required to refine this, as the number and size of care boards becomes clearer. Support functions (renamed to Back Office Care Board Staff) – it is assumed that a number of support functions will be required to assist care boards, such as finance, HR, analytics, business support etc. The Scottish Government is considering the opportunity for shared services and what functions the National NCS structure could provide and which need to be held by care boards at the local level. Communications and administration costs (renamed to Running Costs). These are the general running costs of the board.
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27 This covers aspects such as, audit fees, legal advice, general administration and communications, supplies and services and staff related costs.
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28 Provision has also been made in 2027-28 for the inception costs in preparing the board to launch, such as setting up the IT infrastructure and the recruitment of new board members. Pay and terms and conditions – this currently assumes a phased approach to the movement of local authority staff into care boards. As this will depend on future discussions between the Scottish Government and local authorities, costs are estimated here to show the quantum of the potential impact. Costs rise from 2025/26 to 2026/27 2028-29 to 2031-32 at the top end of the estimate as it is assumed a varying percentage of staff would transfer each year. The lower end of the estimate assumes that no staff would transfer. These costs have been baselined against current pay and terms and conditions costs as far as is possible with existing data, compared to the future direction of travel of public sector terms and conditions. Much of the overall costs of care boards reported here are therefore for front line delivery services. Staff transfer 53. The Scottish Government has agreed that local government continue in its role as a direct provider of social care services. This includes continuing to hold and invest in assets and employ staff directly. Under the Bill as introduced, decisions on the role each local authority wants to play, and associated staffing decisions, will be taken locally once the structure and governance of care boards and their localities have been decided. However, an ability to transfer staff, and assets, is necessary to support the transfer of accountability that may at some point require care boards to take on the ability to deliver services in-house. 54. Table 8A currently assumes a phased approach in which all local authority staff would eventually transfer into care boards. However, it is not a foregone conclusion that this will be the case, and it will depend on future, and ongoing, discussions between care boards and local authorities. The recently adopted Shared Accountability Agreement sets out that staff and assets will remain with the local Authority however, as noted the intention of this document is to establish the potential cost were staff to move as per the provisions in the Bill. Costs are estimated here to show the maximum potential impact. 55. Approximately 75,000 staff are currently employed by local authorities in social work and social care support services, including children’s services and justice social work. If staff were to transfer to the NCS, pay rates and terms and conditions would need to be rationalised within the single service. While it has never been expected that all 75,000 staff will transfer, even in the long term, this represents the maximum limit for estimating costs. Estimating the cost of staff transfers is difficult as all local authorities may have different pay rates and terms and conditions for their staff, The figures for pay and terms and conditions set out in table 8A have been baselined against current assumptions on Fair Work. “Pay” represents the additional cost of increased basic pay rates, while “terms and conditions” represents the cost of other issues, for example increased sick pay or covering increased holiday entitlements and pension contributions. Further assessment and engagement with
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29 local authorities and with the workforce would be required, if the Bill were to be passed as introduced, to determine how many staff were likely to transfer and on what conditions. 56. Costs in table 8A rise from 2028-29 to 2031-32 at the top end of the estimate as it is assumed a varying percentage of staff would transfer each year. The lower end of the estimate assumes that no staff would transfer. Much of the overall costs of care boards reported here are therefore for front line delivery services. 57. It is expected professional expert support will be required to identify costs further in a number of areas including VAT as well as assets and pensions were the transfer of staff and assets to occur. For pensions, a number of options for the provision and ongoing management of pensions have been initially considered for staff who may be affected by any changes. More work and engagement will be required to determine the most suitable and affordable design, as decisions are made on the scope of the NCS. A standard pension contribution rate of 20.9% is currently assumed in the care board costs, based on expected future direction of travel of public sector terms and conditions. Assets directly linked to care delivery will also have to be considered, as to whether ownership or leases will be transferred to new care boards. Data does not currently exist in one place on market value of social care properties, backlog maintenance or other associated costs. This will be further investigated. No capital costs of any asset transfer, or revenue costs of any asset maintenance, are assumed in table 7 or 8 . VAT 58. Currently Integration Joint Boards are established in a similar way to a local authority body, and can therefore reclaim VAT on services. The Scottish Government are committed to securing a VAT neutral status for Care Boards to ensure maximal funding is directed to support front line services. As such, work is underway to understand and mitigate any VAT implications including engagement with HMT and HMRC to discuss options for obtaining this neutral status. 59. Prior to the agreement of a broadly neutral VAT accounting arrangement with HMRC in 2014, the VAT cost impact associated with the establishment of Integrated Authorities under the Public Bodies (Joint Working) (Scotland) Act 2014 was estimated to be around £32 million. After taking account of inflation and making provision for an increase for a larger volume of contracts of between 2% and 3% per annum, the equivalent VAT cost for providing the same services in 2025/26 is estimated to be between £54 million to £60 million. Without this increase in contract volume the cost would be £42 million.
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30 60. Note VAT costs are not assumed in table 7 or 8 at present as we are working towards the assumption that a VAT neutral status will be agreed. 61. After taking into account the re-phasing of the NCS, the NCS Local Go Live date is expected to be 2028/29. The VAT cost estimate for this year, if a VAT neutral status is not achieved and after including further inflation and an assumed annual increase in contract volumes of 2- 3% (lower & upper limits), is £59 million to £69 million. This would be an annual recurring cost. Transfer of functions Where local authorities deliver social care services directly, that delivery may in future transfer to care boards, together with the staff who provide those services. This could involve up to 75,000 employees across social work and social care. Costing of this is difficult as all local authorities may have different pay rates and terms and conditions for their staff, which will need to be rationalised within a single service. The figures for pay and terms and conditions set out in table 8 have been baselined against current assumptions on Fair Work. Decisions will require further assessment and engagement with local authorities and with the workforce, to determine how many staff are likely to transfer and on what conditions. “Pay” represents the additional cost of increased basic pay rates, while “terms and conditions” represents the cost of other issues, for example increased sick pay or covering increased holiday entitlements.
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31 Table 8: Additional costs for Care Boards As per published Financial Memorandum 20 June 2022: Costs to Scottish Administration Costs to care boards Cost Category 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Governance and Board costs 0 0 0 22-33 23-34 Premises and digital 0 2 - 4 10 - 15 63 - 94 69-103 Support services 0 0 0 45 - 67 46 - 69 Administration and communications 0 1-2 2 2-4 4-6 Pay 0 0 0 0 - 43 0 - 43 Terms and Conditions 0 0 0 0-84 0-120 Totals 0 4-6 12-18 132- 326 142-376 Updated as per December 2023: Table 8A: Staff Transfer Costs Scottish Administration Care Boards 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 Pay Parity 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 15 0 - 23 0 - 25 0 - 32 Terms and conditions 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 81 0 - 131 0 - 187 0 - 238 Total 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 96 0 - 154 0 - 212 0 - 270
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32 Table 8B: Care Board Running Costs Scottish Administration Care Boards 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 Back Office (Care Board Staff) 0 0 0 0 0 2 - 7 19 - 90 42 - 92 63 - 95 65 - 98 Premises and IT 0 0 0 0 0 0 - 1 1 - 6 3 - 6 4 - 6 4 - 6 Running Costs 0 0 0 0 0 5 - 22 11 - 53 24 - 54 36 - 55 37 - 56 Governance and Board costs 0 0 0 0 0 0 1 - 3 2 - 3 2 - 3 2 - 4 Total 0 0 0 0 0 7 - 30 32 - 152 71 - 155 105 - 159 108 - 164 *Note – slight variance between Table 7 and the sum of tables 8A and 8B is due to rounding Underlying Calculation Assumptions: The Scottish Social Services Council provided a public sector specific breakdown of their workforce data. This formed the basis of the calculations as it allowed the splitting up of care staff, auxiliaries and managers. The cost of each group was calculated by taking their Whole Time Equivalent against their hourly rate. Hourly rates were based on National Living Wage commitments for care staff, Real Living Wage for auxiliaries and Agenda for Change manager bands for management staff. Varying levels of on costs were applied to determine the potential additional cost. For Care Boards it is assumed that they will now go live in 2028/29 and that there would be 31 to match up with the current Integration Joint Boards (IJBs). Each board is assumed to require staff to run the various functions allowing it to operate effectively such as admin, finance, procurement etc. There is also the requirement to have an executive board. The approach to Care Board costing has changed from the Financial Memorandum in June 2022. The specific elements are detailed below but broadly, given the anticipated size and nature of the Care Boards it was felt that an assessment of Non Departmental Public Body (NDPB) costs would provide a reasonable barometer for the likely costs attributable to running a Care Board. Cost Range – The lower range is based on all staff remaining within the Local Authority and also a phased approach to the establishment of Care Boards, building up from 2028-29 to full running by 2030-31. The upper range is based on a full staff transfer with all Care Boards going
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32 live in 2028-29.
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33 Reasons for Variances: Inflation assumptions have changed, see table 1A for full details Categories have been re-named to better reflect our understanding of how future costs are expected to be incurred. Staff transfer costs have been split out in table 8A with table 8B showing all other running costs. Premises cost estimates have been revised with the approach now being the use of current commercial rental rates and the approximate space size requirements of the anticipated staffing numbers. Edinburgh prices were used as a proxy given they are generally higher than elsewhere in the country, so as not to underestimate the potential liability. The prior estimate had built in a more significant contingency factor given the uncertainty. The reduction of this contingency due to the new costing approach has reduced the premises cost. The new estimate for Care Board rental is in more closely aligned with some of the (NDPB) costs which has given assurance that these are more robust. The approach to IT costs has also changed from the previous iteration. The basis now is the evaluation of annual account data for multiple NDPB with a mid-range figure becoming the estimate applicable, scaled up by the number of Care Boards. Previously, the approach had also factored in large contingency costs for the potential transition and corporate costs given the uncertainty, though this made the cost vastly higher than the comparable figures assessed and so the revised approach felt more closely aligned to the likely outcome Running costs have also been established from assessment of NDPB annual accounts figures. The common elements for the various accounts were taken and then the associated costs were adjusted to reflect the anticipated size and operation of Care Boards. This again brought the overall cost more in line with similar bodies. Costs to local authorities and health boards 62. The If functions were to be transferred transfer of functions from local authorities to the NCS, in line with the Bill as introduced, in particular may this could have additional financial implications These may include including, for example, costs for the transition process, but t. There may also be potential savings on central services such as finance, digital systems and premises, if a significant number of staff move to the NCS, but alternatively local authorities could experience a loss of economies of scale. These costs and savings will depend on what services are to be included in the NCS, when the transfer is to take place and how the transition process will be staged. If this approach were to be taken, the Scottish Government would carry out thorough options appraisal, working with COSLA, to identify these financial implications at the appropriate time and inform the approach taken. Further information would be provided to the Scottish Parliament when the relevant secondary legislation is brought forward.
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34 63. The financial implications for health boards are expected to be less significant, because of the expectation that they will continue to deliver services commissioned by the NCS. As with local authorities, those implications will be considered when more detail of the arrangements is known. Costs on other bodies, businesses or individuals 64. It is not anticipated that the establishment of the NCS and care boards, and the transfer of functions to those bodies, would have any financial implications for any other public bodies, businesses or third sector organisations, or for individuals. 65. If social care functions are transferred from local authorities to care boards, it is assumed that in the first instance, all contracts and arrangements with external organisations for the provision of social care support services will also transfer. Over time, changes to policies on ethical procurement and Fair Work may lead to changes in the requirements on potential providers. While the Bill will enable the Scottish Ministers to promote such policies more effectively, the detail is not set out in the Bill and will be subject to separate financial and regulatory impact assessment. HEALTH AND SOCIAL CARE INFORMATION 66. Part 2 of the Bill gives the Scottish Ministers the power to set up a statutory scheme through Regulations to permit data sharing for the efficient and effective provision of services by, or on behalf of, the NCS and NHS, and to produce information standards to ensure information is processed in a consistent way. This will enable better sharing of information across the health and social care sector, to the benefit of people and professionals. Crucially, it will also support the creation of the nationally- consistent, integrated and accessible electronic social care and health record. The creation of these provisions will have no immediate financial implications for the NCS, NHS or Scottish Government. The NCS consultation noted that improvements to data and digital would require additional investment in data and digital systems locally and nationally. This is expected to cover infrastructure, staffing, training and development costs. The Scottish Government will work closely with people who access support, carers, providers and front line staff to develop the social care and health record. 67. The development of the electronic social care and health record does not arise from the NCS Bill, and is therefore not covered in this financial memorandum. The integrated record requires a full process of discovery and design, which includes co- design with all stakeholders. Work has been initiated on discovery and alpha phases of the integrated record to develop detailed requirements which will inform the development work ahead. At this early stage it is not possible to provide an exact position on the total cost of investment or how the costs will be phased. As part of this work The Scottish Government has begun the drafting of the Strategic Outline Case for the integrated record, which includes an options appraisal and outline of indicative costs for the
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34 integrated record. Through this co-design process and wider work to develop
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35 the evidence base it will be possible to robustly estimate costs. Supporting business cases and appropriate assurance will be created while the process of seeking funding and scope decisions continue.here significant investment will be required. The final costs will depend on user engagement to finalise the ultimate scope and specification, and the outcomes of any future competitive tender processes to deliver those requirements to ensure optimal public value. Scope and specification will be informed by the co-design approach being taken to the NCS. 68. There will also be work to develop digital services to underpin and enable the NCS as well as investment in people to make sure they have the right skills to use digital platforms and analyse data. Again, more investigation and co-design is required to define this. All options will be subject to rigorous assessment to ensure value for money and affordability. REFORMS CONNECTED TO DELIVERY AND REGULATION OF CARE Right to Breaks from Caring NOTE – this section to be updated once new carers population figures are published on 5 December 69. Section 38 of the Bill makes changes to the Carers (Scotland) Act 2016 (“the Carers Act”) to establish a right to personalised short breaks support for carers who have an identified need for that support, through an adult carer support plan (ACSP) or young carer statement (YCS). These changes will adjust and extend the duties of Local Authorities and Integration Authorities, which are expected to pass to care boards when the NCS is established. These duties will lead to additional costs in providing breaks from caring. 70. The Scottish Government also intends to maintain a national short breaks fund, using existing powers7, to enable easy-access support for people in less intensive caring roles. This will build on existing non-statutory voluntary sector short breaks funding. These schemes provide micro grants schemes for unpaid carers to help them take short breaks that meet their needs. Individual grants can be used flexibly, e.g. for a weekend away, entertainment subscription or sporting or hobby equipment. Time To Live grants are delivered locally, usually by local carer centres. Take a Break Scotland grants for carers of disabled children and young people and their families are delivered nationally by the Family Fund. The Scottish Government is committed to increasing this funding to provide easy access to breaks for carers without the need for a support plan or statement. While this fund does not require new legislation, it will have an impact on the costs of providing the personalised support required by the provisions of the Bill, depending on the balance of whether carers access personalised support or easy access breaks. 71. The cost of these measures has been estimated using data on the following: Number of carers by intensity of caring8
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35 7 Social Work (Scotland) Act 1968, section 10 8 Intensity of caring based on the bands of number of hours per week, as per table 9.
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36 Balance of replacement care between residential and home based Unit costs for replacement care, carer breaks and easy access support Cost and Whole Time Equivalent for young carer support workers. 72. There are number of areas of uncertainty, for which information is incomplete or missing, where assumptions have had to be made, in particular: the number of carers who will seek to exercise their right to breaks the average amount of replacement care required for personalised support the balance of breaks between personalised support and easy access support current levels of local authority and Integration Authority expenditure on breaks and replacement care, for which local authority systems do not generally differentiate short breaks support from other services, and the rate at which demand and available provision will build over time. 73. The full set of assumptions for all groups is extensive, the following example is provided for illustration: For adult carers providing over 50 hours of care per week, it is assumed that 50% of those with an ACSP will take up replacement care, and that this will average 4 weeks per carer per year, of which 65% is assumed to be residential care and the remainder intensive homecare at 22 hours per week. Additionally, it is assumed that 60% of this group will take up a carer break (additional support to help them recharge during their time away from caring), averaging 3 breaks per year. These figures can then be combined with the numbers of carers set out in table 10 and the costs of breaks9 identified above and netted against estimates of existing expenditure to estimate the total net cost of implementing breaks for carers. 74. Table 9 shows how a selection of the assumptions vary for different intensity groups.
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36 9 Care home respite at weighted average of cost of £981 per week and homecare at £21 per hour. Carer breaks costed at £300 per break. All at 2022/23 prices.
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37 Table 9: Assumptions used in calculating costs of breaks from caring <20 hours a week 20 - 34 hours a week 35 - 49 hours a week 50 or more hours Proportion of adult carers with ACSP that receive replacement care (%) 5% 10% 20% 50% Number of weeks replacement care per carer (Adult carers) 1 2 3 4 Proportion of adult carers with ACSP that receive carer break (%) 10% 20% 40% 60% Number of carer breaks per adult carer 1.0 2.0 2.0 3.0 Proportion of young carers with YCS with activity enabling break 100% 100% 100% 100% Proportion of young carers with YCS receiving replacement care 0% 100% 100% 100% Easy access payment (per carer)10 £300.0 £330 Uptake of easy access support by adult carers who do not receive personalised support 10% 40% 40% 40% Uptake of easy access support by young carers 10% 40% 40% 40% * The only variances since the original Finance Memo are an update to the easy access payment (per carer) from £300 to £330 and to include replacement care for young carers caring for 20 + hours per week. 75. The calculations produce estimates for a future steady state of support in which the proportion of carers with an ACSP and or a YCS has reached the same proportions as those assumed in the Financial Memorandum for the Carers (Scotland) Bill11, specifically 34% of adult carers and 64% of young carers (see table 10, rows 2 and 5 for steady state number of carers with ACSP and YCS respectively). The estimates for personalised support are based on the number of carers with plans and statements, and those for easy access support are based on the balance of carers who do not have plans/statements. 10 Estimate based on feedback from providers of Time to Live and Take a Break Scotland grants
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37 11 https://archive2021.parliament.scot/S4_Bills/Carers%20(Scotland)%20Bill/b61s4-introd-en.pdf
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38 76. Table 10 shows the number of carers (updated using the latest published carer population data12) by intensity of caring and our estimate for how many will have ACSP/YCS in the steady state. The distributions assume that 80% of carers in the 50+ hours per week band will have plans/statements, with reducing proportions for less intensive bands and with the balance in the <20 hours per week band to give total proportions of 34% and 64%. As per December 2023: 12 Scotland’s Carers update release Scotland's Carers - gov.scot (www.gov.scot)
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39 Table 10: Number of carers and proportion expected to have ACSP / YCS in steady state As per published Financial Memorandum 20 June 2022: <20 hours per week 20 - 34 hours per week 35 - 49 hours per week 50+ hours per week Total Number of adult carers 624,864 59,280 29,640 125,215 839,000 Number of carers with ACSP 143,592 23,712 17,784 100,172 285,260 Proportion of carers with ASCP 23% 40% 60% 80% 34% Number of young carers 27,900 900 300 900 30,000 Number of carers with YCS 17,670 585 225 720 19,200 Proportion of carers with YCS 63% 65% 75% 80% 64%
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40 Updated as per December 2023: <20 hours per week 20 - 34 hours per week 35 - 49 hours per week 50+ hours per week Total Number of adult carers 487,507 58,210 36,381 123,696 705,793 Number of carers with ACSP 95,901 23,284 21,829 98,957 239,970 Proportion of carers with ASCP 20% 40% 60% 80% 34% Number of young carers 22,676 1,043 0 1,043 24,761 Number of carers with YCS 14,335 678 0 834 15,847 Proportion of carers with YCS 63% 65% N/A 80% 64% 77. Based on Carers Census13 data on the numbers of such plans and statements, the Scottish Government estimates that it will take approximately ten years to reach the steady state number of carers with plans and statements, increasing on average by approximately 27,000 22,000 plans and 1,600 1,300 statements per year from 2025/26 to 2034/35. This assumes the right to personalised short breaks support under the Carers Act, established by the Bill, is implemented from April 2025, although the implementation date is yet to be decided. Table 11 shows estimated additional costs of the Carers Act personalised breaks element of the proposed right to breaks established by the Bill. (Note that the summary table (Table 1) only shows costs to 2026-27 2031- 32). 13 Carers Census, Scotland, 2019-20 and 2020-21 - gov.scot (www.gov.scot) and Carers Census, Scotland, 2021-22 - gov.scot (www.gov.scot)
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41 Table 11: Costs of Carers Act breaks (£m) – costs to local authorities / Integration Authorities, transferring to Care Boards As per published Financial Memorandum on 20 June 2022: 2023-24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 0 0 13 27 40 53 66 80 93 106 120 133 Lower Estimate 0 0 8 16 25 33 41 49 58 66 74 82 Updated as per December 2023: 2023-24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 0 0 19 38 59 80 102 125 148 173 198 225 Lower Estimate 0 0 13 27 40 55 70 86 102 119 137 155 Central Estimate 0 0 16 32 50 67 86 105 125 146 167 190 Reasons for Variances: Updating estimates using the latest available data on carer population and intensity of caring (as Table 10); Uprating the unit costs from 2022/23 to 2023/24 prices; Including an estimate for replacement care for young carers caring for 20+ hours per week as part of Carers Act short break support; Increasing the number of carers to reflect the projected increase due to demographic change over the growth period; Inflating the estimated costs from 2023/24 prices to nominal prices (in line with the approach in the rest of the Financial Memorandum); Central estimates have been added to the updated table as a new row.
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42 78. Table 12 on the costs of easy access breaks is included to show the balance of funding, although this is not a consequence of the Bill (and is not included in the total costs of the Bill in Table 1). Table 12 includes estimated costs from 2023-24 as this support does not require new legislation and can therefore be implemented immediately is already building on existing support. The model assumes this support builds over time allowing the sector to expand its staffing and provision while growing the numbers of unpaid carers being supported. These figures are predicted to reach a steady state towards the middle of the period as higher numbers of carers are expected to be receiving personalised breaks under the Carers Act. Table 12: Costs of easy access breaks (£m) – costs to the Scottish Administration: As per published Financial Memorandum on 20 June 2022: 2023-24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 10 15 20 25 30 35 37 37 37 37 37 37 Lower Estimate 10 15 20 25 30 34 34 34 34 34 34 34 Updated as per December 2023: Easy access breaks (Scottish Ministers) 2023-24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 0 5 10 15 21 26 32 34 35 35 36 37 Lower Estimate 0 5 10 15 21 26 30 31 31 32 33 33 Central Estimate 0 5 10 15 21 26 32 33 33 34 35 36 Reasons for Variances: Updating estimates using the latest available data on carer population data and intensity of caring (as Table 10); Uprating the unit costs from 2022/23 to 2023/24 prices; Bringing the estimate for existing funding in line with Scottish Government easy-access breaks budgets for 2023/24;
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43 Increasing the number of carers to reflect the projected increase due to demographic change over the growth period; Inflating the estimated costs from 2023/24 prices to nominal prices (in line with the approach in the rest of the Financial Memorandum). 79. Combining the estimates for personalised breaks under the Carers Act (as a consequence of the Bill) and easy access breaks, the cost of the steady state is estimated to be between £116m and £170m £188m and £261m by 2034/35, with the central estimate being a cost of £143m £225m. at 2034/35 prices (£158, £221m and £190m respectively at 2023/24 prices). Table 13: Total additional cost of rights to breaks (£m) As per published Financial Memorandum on 20 June 2022: 2023- 24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 10 15 33 52 70 88 103 117 130 143 157 170 Lower Estimate 10 15 28 41 55 67 75 83 92 100 108 116 Central Estimate 10 15 31 47 62 78 90 101 111 122 133 143
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44 Updated as per December 2023: Total Carers Act & Easy Access Breaks 2023-24 24-25 25-26 26-27 27-28 28-29 29-30 30-31 31-32 32-33 33-34 34-35 £m £m £m £m £m £m £m £m £m £m £m £m Upper Estimate 0 5 29 54 79 106 134 158 183 208 234 261 Lower Estimate 0 5 23 42 61 81 100 117 133 151 169 188 Central Estimate 0 5 26 48 70 94 118 138 159 180 202 225 Reasons for Variances: See reasons at Tables 11 and 12 above. 80. Recognising the considerable uncertainty inherent in these estimates, it will be important to continue to monitor the rate of growth in provision of breaks from caring as implementation progresses and refine estimates accordingly. Decisions on funding will also be dependent on future government spending reviews. The Carers Census already aims to collect information about breaks provided under the existing Carers Act. However, this information has proven challenging for organisations to return and so the data available is largely incomplete. The Carers Census is currently being has been reviewed and work is ongoing to support local areas to improve the collection. Savings due to rights to breaks 81. The Scottish Government estimates unpaid care is currently saving Scotland £12.8 billion per year in social care costs, plus £320 million in health care costs – a total saving of £13.1 billion per year14. 82. The measures in the Bill are designed to protect carers’ health and wellbeing, helping sustain caring relationships. This will reduce costs which would otherwise arise for the NHS, Local Authorities and Integration Authorities, and subsequently the NCS, through unplanned hospital admissions, failed hospital discharge and additional residential care when caring relationships break down. There are around 156,000 people in Scotland providing 35 hours of unpaid care or more per week15. If the right to breaks helps prevent 1% of these intensive caring relationships 14 Scottish government calculation of replacement care and hospital days avoided (April 2022) using results in Weaver et al: Does availability of informal care within the household impact hospitalisation? Health Econ Policy Law. 2014 Jan; 9(1):71-93.
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44 15 The number of adult carers is based on the Scottish Health Survey (SHeS) 2020 (published at: Scotland’s carers: update release - gov.scot (www.gov.scot), Scottish Government 2021) and the profile is based on Scottish Surveys Core Questions (SSQC) data (2016-19).
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45 breaking down, that will save £68 million per year in health and social care costs. If the right protects 5% of these intensive caring relationships, the saving will be £318 million per year16. 83. Research suggests that unpaid carers have on average 1117 fewer days of full heath per year compared with non-carers. For Scotland’s unpaid carers this is 9.6 million days per year. If these measures reduce carer ill health by 1%, that will avoid 96,000 days of ill health valued £8 million per year. If they reduce days of carer ill health by 5%, that will result in 478,000 fewer days of ill health, valued at £39 million per year18. 84. There are around 268,000 people in Scotland balancing paid work with an unpaid caring role19. Women make up 61% of unpaid carers of working age20. Protecting carer health and wellbeing should also lead to wider benefits to the Scottish economy by enabling more carers to remain economically active, reducing the gender pay gap and social security costs. It is not possible to precisely estimate the size of these wider savings and benefits but they are expected to be considerable. Additional breaks can make the difference to help people remain in work or return to work. If the right to breaks helps 1% more carers to remain in work, the benefit to them and to Scotland’s economy would be worth £71 million21. If it means an extra 5% are working, the benefit would be £353 million per year. This would also reduce the current £340 million per year expenditure on Carer's Allowance (DWP) and on Carer's Allowance Supplement (Social Security Scotland). “Anne’s Law” – Visits to or by care home residents 85. Section 39 makes provision for “Anne’s Law”, which ensure that people living in adult care homes to see the people important to them even during outbreaks of infectious disease. The financial cost of these measures should be viewed in the context of the progress made since 2021 in maximising meaningful social connections and visiting in adult care homes, effectively readying the care home sector for the implementation of the statutory requirements provided for in the Bill. 86. In September 2021, the Scottish Government in collaboration with Public Health Scotland, the Adult Social Care Clinical and Professional Advisory Group and groups representing families and care home provider published updated “Open with Care” visiting guidance. 16 Scottish government analysis of replacement care and hospitalisation (April 2022) 17 Informal carers’ health-related quality of life and patient experience in primary care: evidence from 195,364 carers in England responding to a national survey. Thomas et al. BMC Family Practice (2015) 16:62
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45 18 Scottish government calculation of unpaid carer days of ill health (April 2022) 19 Scotland's Carers report, Scottish Government, 2015: www.gov.scot/publications/scotlands-carers based on Scotland's Census 2011. 20 Scotland's Carers report, Scottish Government, 2015: www.gov.scot/publications/scotlands-carers 21 Scottish government calculation using data from Annual Analysis of Hours and Earnings (ASHE) 2021, ONS
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46 This allowed recommended that for people living in care homes are supported to being able to nominate “named visitors” to see them - even in a COVID-19 outbreak situation. The guidance promotes and encourages care homes to maximise opportunities for meaningful contact both in and away from the home. It has been adopted in the most part and serves to practicably and financially prepare the sector for Anne’s Law. 87. On 31 March 2022, the Scottish Government utilised powers conferred by Section 50 of the Public Services Reform (Scotland) Act 2010 and introduced two new statutory Health and Social Care Standards relating to visiting. The Health and Social Care Standards set out what people should expect when experiencing health, social care or social work services in Scotland. As with the current “Open with Care” guidance. They are taken into account by the Care Inspectorate in relation to inspections, and registration, of social care services.the Care Inspectorate is required, by law to consider how care service providers are upholding the Standards both in relation to registering and inspecting care services. 88. The Bill will enable the Scottish Ministers to exercise a new power under subsection 2 of the Public Services Reform (Scotland) Act 2010 to require care home service providers to comply with any direction issued by the Ministers about visits to residents, and visits by residents, of accommodation provided by a care home service (“a visiting direction”). The use of Directions will allow the Scottish Ministers to set expectations around supporting meaningful connection and visiting and potentially respond quickly to what may be a rapidly developing situation. and impose requirements on care homes to remove any barriers to full and normalised visits that may have emerged. This will build further on the principles established through the guidance and Health and Social Care Standards and ensure that Anne’s Law is enshrined in legislation. 89. As a result of this incremental approach, the costs of supporting implementing visiting rights and meaningful contact in care homes fall to both the introduction of the new Standards and to the Bill, and it is not possible to precisely separate them. Costs to other bodies and businesses 90. Representatives from care home service providers, local care home oversight teams (now known as Collborative Care Home Support Teams) , Care Inspectorate and Public Health form part of the Scottish Government’s expert reference group on Anne’s Law , along with families of care home residents, and help shape and promote the guidance. It is expected that there will be some costs to these groups for example care home providers and those supporting care homes, to promote and champion Anne’s Law through in their staff and provider awareness sessions, formal training, updating visiting policies and for printing leaflets and other administration. However, there has already been work to support the adoption of the new Health and Social Care standards around visiting and no specific costs have been highlighted by care home providers, and . Accordingly it is anticipated that the new requirements will be absorbed within the usual costs of updating training and other materials. There are is potentially a time burden associated with any proposed local oversight and assurance arrangements for Anne’s Law involving professional leads from Local
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46 Authorities and NHS Boards. However this could be facilitated through existing local mechanisms for care home support and is not expected to result in additional staff costs.
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47 91. The Scottish Government will continue to consult widely on the anticipated practical application of Anne’s Law within the expected provisions of the legislation and make note in any divergence from current guidance and potential costs. While this process is ongoing, it has not highlighted additional costs to the sector. Costs to the Care Inspectorate 92. Currently, complaints regarding visiting can be made to registered services, or directly to the Care Inspectorate and for individual staff via the Scottish Social Services Council (SSSC). Less commonly cComplaints can also go via the local authority, the Health and Social Care Partnership (HSCP), or the individual NHS health board. If individuals are not happy with the decision relating to their complaint, from any of these bodies, they can approach the Scottish Public Services Ombudsman 93. The Scottish Government estimates that there will be heightened public interest in the new legislation, and this which may result in adults living in care homes, or their friends and families, people exercising their right to complain. Therefore Ccomplaints to the Care Inspectorate are may expected to increase in the short term, although current arrangements for adopting the new Health and Social Care Standards and supporting visiting during outbreaks are already well adopted within the sector. while improvements to visiting become embedded in the sector, but to fall away within 32 years. This is reflected in part in the additional costs below. Any increase in complaints via other routes is not expected to be significant. Additional Costs 94. The Care Inspectorate will also incur costs in the lead up to and following the introduction of Anne’s Law, as there is a need to promote the guidance, the new Standards and prepare the sector for Anne’s Law with the aim of building capacity and capability within the sector for improvement. 95. We have worked with the Care Inspectorate to determine the work over and above their core responsibilities. We have agreed a package of additional measures, materials and resources to support preparation for Anne’s Law “Open with Care” guidance including support for care homes to develop new policies reflecting the Health and Social Care Standards; staff induction and internal and external training; self-evaluation improvement support for services; and developing capacity to enable the immediate resolution of complaints through direct engagement with providers and services. 96. In the year 2022/23, total Care Inspectorate costs to support the introduction of Anne’s Law are was estimated to be £186,000, and £90,000 in 2023-24 and £50,000 in 2024-25 as shown in table 14. Thereafter, improvements to visiting will become embedded in the sector and
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47 we estimate that costs will fall away from year 20245/256 onwards.
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48 Table 14: Costs to the Care Inspectorate of implementing Anne’s Law Cost Category 2022-23 2023-24 2024-25 2025-26 2026-27 £m £m £m £m £m Other public bodies (Care Inspectorate) £0.186 £0.090 £0.050 0 0 Benefits 97. The financial cost of Anne’s Law should also be viewed in the context of the benefits to the health and wellbeing of adult care home residents and their friends and families, with a case to be made that that there will be savings realised in other aspects of the Health and Social Care system. 98. A consultation was launched on 24 September 2021 to seek views on the Scottish Government’s proposals for delivering Anne’s Law in primary legislation. Analysis of the consultation showed that there is considerable support for the approach of introducing Anne’s Law. Many respondents commented on their own experiences of family members being isolated in care homes over the course of the pandemic and the lasting harm this has caused. 99. Reference to the potential individual and wider system benefits because of improved health and wellbeing was highlighted by NHS Greater Glasgow and Clyde: "There is a wide range of evidence internationally that social connectedness is required for good health. Anne's Law would reduce social isolation, poor mental health and associated effects on physical health. This creates a more efficient and effective service as there are less care needs for staff to manage and residents, carers and staff are happier" Changes to powers and functions of the Care Inspectorate 100. A number of proposals have been made in recent years to enhance and strengthen the powers currently available to the Care Inspectorate, as the independent regulator and scrutiny body for social care services under the Public Services Reform (Scotland) Act 2010 (“the 2010 Act”). These proposals would enable the regulator to speedily take action with poor performing services, better protect social care users, and drive up the consistency and quality of care expected across all social care services in Scotland. The Bill makes provision for two changes which require primary legislation.
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49 Enhanced enforcement powers 101. Section 42 of the Bill amends the 2010 Act to give the Scottish Ministers power to set out circumstances in which the Care Inspectorate can move directly to proposing to cancel a care service’s registration without first issuing an improvement notice, including on the basis of previous enforcement action. 102. It is not anticipated that the enhanced criteria to propose to cancel a service’s registration would impose any additional costs or resource requirements on the Care Inspectorate, care providers or any other organisation. The change is not expected to lead to any increase in enforcement cases, but it will enable the Care Inspectorate to cancel a service’s registration more quickly, therefore better protecting social care users. Additional joint inspection powers 103. Section 43 enables the Healthcare Improvement Scotland (HIS) to assist the Care Inspectorate to carry out inspections and the option to charge the Care Inspectorate a reasonable fee determined by HIS for any assistance provided by it. HIS could be asked to provide additional expertise to contribute to an inspection led by the Care Inspectorate, for example, advice on infection prevention and control in care homes. Any request for assistance from HIS is expected to be in exceptional circumstances only, such as during a pandemic. Should the request be for short- term assistance with a small number of inspections then this may be delivered within HIS’ existing resources. In the unlikely scenario that HIS assistance is requested for a larger number of inspections or over a longer time period HIS may request payment to cover additional staff costs they incur. Experience during the Covid pandemic suggests that costs might be between £1000 and £1500 per inspection, if required. No costs for this provision have been included in table 1 because it is not possible to predict when, or whether, such exceptional circumstances might arise.
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1 National Care Service (Scotland) Bill – Financial Implications of Proposed Changes Introduction: 1. In support of the National Care Service (Scotland) Bill, the Scottish Government have provided an update to accompany the Financial Memorandum (FM) that outlines the costs associated with the Bill as introduced. 2. Following the agreement between COSLA and the Scottish Government on shared accountability for the NCS, the Scottish Government proposes to bring forward changes to the Bill at Stage 2 which, if agreed by Parliament, will result in a significant change to the underlying assumptions associated with the FM. Accordingly, this paper provides a further revision of the updated costings to reflect the proposed changes, in so far as these can be estimated at this stage. The main differentiating factors between the updated FM and the Shared Accountability agreement focus on reforming the current Integration Joint Boards (IJB) as opposed to creating new public bodies (Care Boards), to remove the potential for any staff transfer from Local Authorities as well as adding the costs associated with the establishment of a National Board. For the purposes of this paper the reformed IJBs will be referred to as Integration Authorities (IA).
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2 Updated Financial Memorandum – Bill as introduced 3. Table 1 sets out the costs from the updated FM detailing the range of costs associated with the Bill as Introduced. Table 1 – Updated Financial Memorandum – Total Costs of Bill Provision Sector 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions Total estimated costs of Bill provisions 13 11 - 13 13 - 17 32 - 46 45 - 64 64 – 115 105 – 353 158 – 438 210 – 524 229 – 609 Establishment and running of NCS at national level – table 6 Scottish Administration 13 11 - 13 13 - 17 19 - 27 18 - 26 17 – 26 17 – 26 18 – 27 18 – 28 18 – 28 Establishment and running of care boards – table 7 Scottish Administration 0 0 0 0 0 7 - 30 0 0 0 0 Care Boards 0 0 0 0 0 0 33 - 247 70 - 309 106 - 371 109 - 433 Total Establishment and running of care board 0 0 0 0 0 7 - 30 33 - 247 70 - 309 106 - 371 109 - 433 Total NCS costs 13 11 - 13 13 - 17 19 - 27 18 - 26 24 – 56 50 – 273 88 – 336 124 – 399 127 - 461 Right to breaks from caring* - table 11 Social Care / Care Boards 0 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 Anne’s Law – table 14 Care Inspectorate* 0 0 0 0 0 0 0 0 0 0
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3 Total right to breaks & Anne's law 0 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 (Table numbers refer to the corresponding table in the update to the FM) (*The costs relating to the Care Inspectorate for Anne’s Law are not £0 throughout but instead £186k in 2022/23, £90k in 2023/24 and £50k in 2024/25) Table 2 sets out revised costs for the NCS, taking account of the Scottish Government’s proposed changes, where these can be estimated at this time. Table 2 – Revised cost reflecting proposed changes Sector 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions Total estimated costs of Bill provisions – subject to Shared Accountability agreement 13 11 - 13 13 - 18 33 - 48 50 - 72 70 – 104 86 – 126 102 – 149 118 – 175 135 – 198 Establishment and running of NCS at national level Scottish Administration 13 11 - 13 13 - 18 20 - 29 21 - 31 20 – 31 21 – 31 22 – 32 22 – 34 22 – 34 Total Establishment and running of Reformed IAs Reformed IAs 0 0 0 0 2 - 3 10 - 14 10 - 15 10 - 15 10 - 16 11 - 16 Total NCS costs 13 11 - 13 13 - 18 20 - 29 23 - 34 30 – 45 31 – 46 32 – 47 32 – 50 33 – 50 Right to breaks from caring* Social Care 0 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 Anne’s Law Care Inspectorate * 0 0 0 0 0 0 0 0 0 0 Total right to breaks & Anne's law 0 0 0 13 - 19 27 - 38 40 - 59 55 - 80 70 - 102 86 - 125 102 - 148 (*The costs relating to the Care Inspectorate for Anne’s Law are not £0 throughout but instead £186k in 2022/23, £90k in 2023/24 and £50k in 2024/25) For the purposes of consistency and to provide a direct comparison to the update to the FM the costs from ‘Rights to break from
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4 caring’ have been included. However, the shared accountability agreement has no impact upon these cost estimates and so in
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5 Table 3 below, the variance assessed is those costs directly attributable to the NCS development. These are the ‘Total NCS Costs’ line in the above tables. Variances & Assumptions: 4. Table 3 sets out the overall variance between the updated FM and the costs reflecting the proposed changes. Table 3 – Variance analysis between the updated FM and the Costs reflecting the proposed changes 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions Total estimated costs of Bill provisions (FM) 13 11 - 13 13 - 17 19 - 27 18 - 26 24 – 56 50 – 273 88 – 336 124 – 399 127 - 461 Total estimated costs of Shared Accountability 13 11 - 13 13 - 18 20 - 29 23 - 34 30 – 45 31 – 46 32 – 47 32 – 50 33 – 50 Variance 0 0 to 0 0 to 1 1 to 2 5 to 8 6 to -11 -19 to -227 -56 to -289 -92 to -349 -94 to -411 5. There are three significant changes from the updated FM to the shared accountability costings that drive the difference in estimates. Under the shared accountability agreement, Local Authorities will retain responsibility for delivering social work and social care services and there will be no transfer of staff and assets. This means that business as usual expenditure will remain and there will be no additional costs associated with the movement of staff. The basis of the cost was transferring circa 75,000 social care staff over to terms and conditions baselined against current assumptions on Fair Work and a change in employer pension contribution rates. At the start of the phased implementation in 2028-29, this was estimated to be £96m rising to £270m per annum in 2031-32 at full implementation. This is reflected in Table 8A of the updated FM. 6. The second substantial change is that the FM assumed there would be 31 Care Boards created along with the associated functions required to run these, Table 8B of the FM sets out the detail of these costs. However, alternative mechanisms to delivering policy mandates through reforming current local structures are being explored. Reforming Integration Authorities (IA) rather than creating new Care Board public bodies would result in a significant cost associated with the setup, operation and governance of these new Boards being removed, with some new, but smaller, costs being incurred in place. The detail of the proposals is currently being worked through as part of the ongoing Co-Design with service users and discussions with COSLA, NHS and partners to find the optimal operating model but associated costs will likely include:
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6 Increased support for lived experience representatives on IA boards, including support provided for those who undertake caring responsibilities to facilitate their involvement. Greater training and development and induction support for all board and committee members. Strengthening of localities through increased community engagement. This will entail the creation of additional posts to engage more fully within the localities, addressing and supporting members of the community to ensure their voices are heard. There may be the provision made for the IA to directly employ staff such as the Chief Officer and so provision has also been made for a centrally hosted team who will manage the operational requirements of the transfer such as HR and payroll. Table 4 below is a comparator to Table 8B of the updated FM. Table 4 – Estimated Care Board / Reformed IA Costs with proposed changes, and variance 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 £ millions £ millions £ millions £ millions £ millions £ millions Staffing 1 – 2 6 - 9 6 - 9 6 - 9 6 - 9 6 - 9 Premises and IT 0 0 0 0 0 0 Running Costs 1 2 2 2 2 - 3 2 - 3 Governance and Board costs 0 2 - 3 2 - 3 2 - 3 2 - 4 2 - 4 Total 2 - 3 10 - 14 10 - 15 10 - 15 10 - 16 11 - 16 FM Table 8B 0 7 - 30 32 - 152 71 - 155 105 - 159 108 - 164 Variance 2 to 3 3 to -16 -22 to -137 -61 to -140 -95 to -143 -97 to -148 * costs in 2026-27 represent the transition costs as the move from IJBs to IAs take place. Breakdown of Costs: 7. The majority of the staffing costs cover the expansion of community engagement teams to support the work with local communities and lived experience groups. There is also provision made for the creation of a small hosted team who will deliver the HR, payroll and associated functions should reformed IAs directly employ the Chief Officer and Chief Finance Officers. These posts are currently employed by Local Authorities or NHS Boards and seconded to the IA. The Premises and IT costs are reduced as the assumption is that existing premises will continue to be used, so there is no additional cost, while a small provision has been made for the expansion in IT requirements related to the additional staff. The running costs provide funding in the form of grant support to
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7 the new lived experience board members to ensure their full participation is not limited by their caring responsibilities, there is also further funding to support the engagement and co-design work of the new locality staff, additional training and development for board members as well as funding to ensure all documents are available in easy read format. Finally, the Governance and Board costs reflect the remuneration of additional lived experience members who will sit on the reformed IA boards. The transitional costs in 2026-27 are those related to the early adoption of the new staff and their associated recruitment, training and equipment in order to ensure a smooth transition into the new operating model. 8. The third significant change is that within the Bill as introduced, there was no provision for the establishment of a National Care Service Board. However, as set out in the letter from the Minister for Social Care, Mental Wellbeing and Sport to the Health, Social Care and Sport Committee on 6 December 2023, COSLA and the Scottish Government have agreed that the NCS should have a National Board to be the main route through which shared accountability is operationalised and managed. As stated in that letter, we are currently developing the delivery mechanism for the National Board. While this may be in the form of a public body, the final shape of the entity is still to be agreed. There is a rigorous approval process within Scottish Government for any new public body and the proposals for this Board will be subject to that in due course. However, for the purposes of this paper, the revised costs presented here have assumed that it will be established as a body with its own legal identity, such as a Non Departmental Public Body (NDPB), as means of identifying the upper range costs for the Board. We are acutely aware however, of the financial pressures faced across Government and so while the costing of a new public body provides assurance over the upper levels of liability, the design approach has also endeavoured to maximise value for money and make the body as streamlined as possible. 9. To determine estimated costs for the National Board, numerous sets of annual accounts of current NDPBs have been assessed to determine consistent cost elements that can be included, based on the anticipated size and function of the National Care Service Board. Community Justice Scotland specifically was identified as being a relevant baseline for subsequent comparison. Table 5 below sets out high level cost estimates for the National Board. It is estimated that Board will go live on the 1 April 2026. Costs associated with the setting up of the National Board are expected in 2024-25 and 2025-26 to enable this go live date.
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8 Table 5 – National Board Cost Cost Area 2024-25 2025-26 2026-27 2027-28 2028-29 2029-30 2030-31 2031-32 £ millions £ millions £ millions £ millions £ millions £ millions £ millions £ millions Staff 0 1 2 - 3 2 - 3 2 - 3 2 - 4 2 - 4 2 - 4 Premises & IT 0 0 0 0 0 0 0 0 Running Costs 0 - 1 1 1 1 1 1 1 1 Governance & Board Costs 0 0 0 0 0 0 0 0 Total 0 - 1 1 - 2 3 - 5 3 - 5 4 - 5 4 - 5 4 - 6 4 - 6 Breakdown of Costs: 10. The staffing cost covers the running of the body, complete with its own operational staffing complement. We have assessed the options for shared services for areas like payroll and HR, such as those found in other public organisations, and have built in provision for other specific activities, for example, to ensure the Board can carry out the functions set out below as well as administration, communications and engagement. The premises and IT costs cover provision for rental costs and the set up and ongoing costs associated with IT capabilities, these are noted as £0 above but that is due to them being below the £0.5m threshold for rounding up, the average annual cost is estimated as £0.2m. The running costs cover the operational costs of the Board with provision for, but not limited to, external legal advice, audit fees, administration and communications, supplies and staff related expenditure. The governance and board costs cover the executive management function and the associated costs attributable to the decision making board, such as member remuneration. Scope & Function 11. The NCS National Board will drive forward improvements across the system by supporting collaborative leadership and greater collaboration between partners. It will also seek to improve quality and consistency of services and ensure services are sustainable and person-centred by undertaking new functions at the national level.. 12. The high level functions of the National Care Service Board are expected to include: setting national strategic direction; developing standards, guidance and operating frameworks;
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9 overseeing and seeking delivery assurance on local strategic plans and ethical commissioning strategies; monitoring system performance; maintaining a support and improvement framework which will aim to provide support to local areas when monitoring indicates that standards are not being met with powers of intervention, when required, as a last resort; ensuring visibility of data, information, and analysis about social care support, social work and primary and community health services through reporting on delivery; national commissioning and procurement by agreement for complex and specialist social care services which will include prison social care; seeking assurance on public protection arrangements; and providing support to local delivery partners. 13. Members of the Board will include Scottish Government, local government, NHS Boards and, importantly, people who access these services, workforce representatives and unpaid carers. The wider membership of the board will be co-designed. We recognise the importance of embedding the voice of the third sector and unions, for example, in the governance structures for the NCS nationally and locally. 14. There are a number of elements that have remained consistent in the cost estimates presented within the updated FM and this revised costing. An internal Scottish Government function would be required either to implement the Bill as introduced or to implement the proposed shared accountability arrangements, to organise and deliver the setup of the NCS and reformed IA / Care Boards. When established, the National Board will need to be supported to fulfil its functions. The intention is for the National Care Board to enhance capacity in the system, therefore staffing arrangements must reflect this approach and remain flexible. Options are still being considered for supporting the National Board. The cost estimates presented in this paper assume that the Board, if established as a separate body with its own legal identity, will require a core staff team of its own with broader support for the work of the Board coming from existing Scottish Government teams. Affordability 15. Throughout the work undertaken on shared accountability and more widely in the ongoing design of the NCS, affordability and achieving value for money is a primary concern. We are acutely aware of the challenging financial position and as highlighted
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10 in Table 3 above, the recurrent operating cost has been substantially reduced with this shared accountability approach. In terms of the additional investment required, Table 2 above sets out the anticipated cost of the NCS development (excluding carer’s breaks) which over the 10 year time frame, at the upper level, sits at £345 million. However, it should be noted that currently we are incurring in excess of £10 million per annum by way of Scottish Government staff, costs which even were the NCS to cease would continue to be incurred. Table 6 below therefore, sets out the NCS development costs compared to the current staff cost. For the purpose of comparison the staff numbers have been kept constant but adjusted for inflation. This table therefore highlights what additional investment would be required excluding those currently employed staff in order to give the truer reflection of the additional liability. Table 6 – Additional Investment 2022/23 202 3/24 2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 £m £m £m £m £m £m £m £m £m £m Total NCS costs 13 - 13 11 - 13 13 - 18 20 - 29 23 - 34 30 - 45 31 - 46 32 - 47 32 - 50 33 - 50 Current Staff Cost 10 10 11 11 11 12 12 12 13 13 New Costs 3 1 - 3 2 - 7 9 - 18 12 - 23 18 - 33 19 - 34 20 - 35 19 - 37 20 - 37 Based on this comparison the additional investment over and above employed civil servants sits between £120 million and £227 million across this 10 year time period. Work will continue to Co-Design the NCS in the most financially sustainable way.