Fair Access and a Threshold of Care Consultation Report final
Argyll and Bute Council · 17 September 2025
Back to Argyll and Bute HSCP Integration Joint Board (IJB) — 17 September 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Fair Access and a Threshold of Care Policy proposal 04 September 2025
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Contents 2. Executive Summary .............................................................................................. 3 3. Background: ......................................................................................................... 3 1. Why did we consult? .......................................................................................... 4 2. What happens if we take no action? .................................................................... 5 3. What did we hope to achieve through the consultation? ....................................... 5 4. Methodology ..................................................................................................... 6 5. How you engaged with us and what you said ........................................................ 7 The in person response ......................................................................................... 7 The online response ............................................................................................ 10 Written Survey Response ................................................................................. 14 6. Professional response ........................................................................................ 20 7. Our findings ....................................................................................................... 22 8. Recommendations ............................................................................................. 23 9. Next Steps ......................................................................................................... 25 10. Appendices ...................................................................................................... 26 In person summary response. .............................................................................. 26
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2. Executive Summary This report compiles the consultation and outline response on a proposed threshold of social care consultation. The proposal was to establish a policy of a threshold of care at 25 hours equivalent to a residential care placement. It was not based on cost, as care has a different cost in different geographical areas of Argyll & Bute. Between 24 July and 31 August, Argyll and Bute Health and Social Care Partnership conducted a staff and subsequent public consultation on proposed changes to the delivery of Care at Home services. The consultation aimed to gather views from communities, staff, providers, and carers in response to increasing demand, workforce challenges, and financial constraints in rural care delivery. The consultation sought feedback on a proposed policy introducing a review threshold for Care at Home hours, intended to support fair access and sustainable service delivery—not as a ‘cap’, but as a trigger to assess the sustainability of care delivery. Responses were received through both in-person sessions and an online survey. In- person feedback was generally more balanced, while online responses expressed stronger agreement or disagreement, particularly around the risk of residential or out of area care and perceived flexibility of care. The consultation was attended across Argyll & Bute in person, by Microsoft Teams and with 232 online responses by survey. Stakeholder groups were undertaken to ensure that key staff and service providers could explore and input into the consultation response. The consultation elicited a response on the wide nature of care delivered in communities. We have valued this conversation, listened and taken on board this wider contribution. The consultation provided valuable insights that will inform the final policy proposal. While there is recognition of the need for change, stakeholders emphasised the importance of flexibility, fairness, and maintaining local, person-centred care. The proposal to the Integration Joint Board will be made with this report as supporting information on 17 September 2025. 3. Background: Care at home is the main way in which we support adults in our communities. We have 3 main ways of delivering the service, independent sector (or commissioned providers), internal staff or agency (not employed or a commissioned provider). There are a range of different costs depending on where in Argyll & Bute and how the service is delivered. The cost of the service is based on a cost per hour of care provided but there are many factors which impact on the ability to deliver care including skilled workforce, geography and available financial resource.
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In our consultation proposal we outlined some of the challenges we have in delivering this important care. We want to try and make access to this care fairer and to allow us to make best use of the financial and staff resources we have and ensure we work within the financial resources we have. In May 2025 a proposal was made that the HSCP explore the option of introducing a “ceiling of care” or a threshold level of care which was available to an individual. The Integration Joint Board agreed that the HSCP should explore this, we were asked to assess the impact of the change, engage and consult and identify the risk of a change and an internal policy of the delivery of care through this consultation. We proposed a threshold level of 25 hours of social care per week before any additional care planning. In May 2025 our data identified only 6% of the total number of people receiving care were over 25 hours of care per week. This did not include nursing or other health care provided by the HSCP. We are consulting on care at home for adults in this consultation, this primarily affects older adults receiving social care and not supported living. What did this mean in the consultation? • This means we would put a threshold or limit on the amount of care that could be arranged at 25 hours per week • If your assessed care need was greater than this, we would put different planning and approval in place to ensure that we were prioritising need and maintaining fair access to care. This may require consideration of residential care if appropriate or different ways of delivering your care. • This did not mean that you cannot access more than 25 hours per week of care at home – but it may need more planning and approval dependent on your circumstances. • We hoped this would make sure we can still provide fair access for those with more moderate or short term care needs within the staff and financial resources we have. • We wanted to identify as part of the policy development what the exemptions need to be in Argyll & Bute, for example when someone may quickly need end of life care or as part of public protection 1. Why did we consult? A number of Local Authorities across Scotland are addressing how they deliver social care either operationally or through policy. Social care is a key resource in ensuring our whole system of rural services are available we wanted to speak with communities, staff, providers, carers and their representatives. Rurally we have some specific challenges:
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• Increasing demand for services as people live longer and with more complex needs • Workforce shortages and in some areas we have full employment • Cost of social care delivery • Not spending beyond available budget We consulted as a change in how we deliver care would be a change of policy, providing some additional parameters as to how staff would work and how they would get assessed care approved. We wanted to gather the views of all the people who may be affected by this to inform our final assessment and policy proposal. In taking action to support how we deliver services within resource we are also making other changes in how we manage our services. This includes increased efficiency and oversight of activity, the care at home redesign, developing a longer term workforce plan and care home planning. 2. What happens if we take no action? We need to take some action for a number of reasons: 1. We are legally required to operate within the budget provided for us to deliver Health and Social Care services. If we take no action to reduce spend, we will be in breach of this legal requirement. 2. We know that we have an ageing population and people are living longer with more complex needs that will require care in Argyll and Bute. This this trend is expected to continue into the 2040’s. We already have staffing shortages in some areas and we expect the working age population to decline further. If we do nothing to make best use of our resources, we will increasingly find that we are unable to meet care needs, we are trying to manage these pressures in a planned rather than reactive way. This proposed action will impact on a relatively small number of people. We will ensure that all those who are currently receiving care above the threshold will still receive care that is appropriate to their needs, but this may be in a different way. The HSCP expects to be managing increasing demand for social care due to the ageing population, lack of workforce and severe financial constraints for the foreseeable future 3. What did we hope to achieve through the consultation? 1. We wanted to gather information that will inform our overall policy, integrated impact assessment and final proposal to the board
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We chose to do this by: 2. Speaking with our communities to hear what they think about this proposal. This included our service users, carer and wider community. 3. Speaking to those who represent our carers and work with them to gain an understanding of how this proposal might affect unpaid carers 4. Speaking with our staff to find out what impact it will have on how they do their job 5. Speaking with our independent care sector providers and work with them to help provide care services now and for the future 6. We want to be able to answer questions about how you can get the care you need if you need more than the 25 hours of care or if your care needs change for example care at the end of life. 7. Analysing the responses from questionnaires and in person community conversations 8. Providing assurance that we are doing other things within our care services to address how we deliver care at home Scope: The scope of the consultation was on care delivered through the Care at Home service not supported living or health services e.g. community nursing. 4. Methodology • Approach: The consultation was conducted using an online platform engagementhq which supported a single place of contact to ask questions, complete a survey and advertise in person consultation. In person consultation took place across localities with two sessions in each location using the questions noted in appendices. Social media, direct communication and word of mouth was used to promote the consultation with some poster usage. All documents and timeline information can be found at the following link: https://nhsh.uk.engagementhq.com/argyll-and-bute-hscp-threshold-of-care- policy-consultation Participants: Communities, carers representatives, care providers, managers, social workers, occupational therapists. All staff received briefings and were encouraged to participate. NHS Highland as the host organisation of engagement HQ offered input in developing our consultation and support from an anonymous oversight group as part of the publishing process. We would reflect that support provided through this process and the oversight group was invaluable in supporting the final consultation for publication. Staff contact took place ahead of the public consultation taking place. We have learned previously that ensuring we have face to face routes for our operational leadership beyond general briefing is important in the support of our staff.
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This consultation was not major service change. Challenge: We discovered with social media in that posts were not shared/published by Facebook and we took alternative action when we received feedback. We will take this learning for future consultations as this impacted the reach of our online session. 5. How you engaged with us and what you said In this section we will summarise the findings and broad themes that were identified as part of the consultation. The in person response We met with you in communities and asked a number of questions about Care at home (full response in appendices). Q1. What does good Care at Home look like? You told us good care was flexible, responsive and not task driven and delivered by well trained staff who took pride in their role. You told us those staff should be well paid and should be able to communicate and build relationships (with lots of good examples of this and some requests for more continuity of care). You wanted flexibility around waking and bedtimes. You told us you wanted ‘reablement’ as a starting point to ensure that we were starting off by getting someone to the best position they could be in to maximise their independence. You wanted better information on Self-Directed Support and the Options available to choose care. Reablement is a time-limited, goal-oriented intervention delivered in a person’s home or community setting. It focuses on helping individuals relearn daily living skills, such as washing, dressing, cooking, and mobility, with the aim of reducing dependency on long-term care services You told us that community and local solutions should be considered as part of care with people better signposted to what is available locally with good support for carers. We are aware this should be part of a holistic assessment; all care within a care plan may not be formal social care. You want good multi-disciplinary care planning including the GP with access to care and health records. You told us accurate assessment and ongoing review was important as sometimes this is not your experience.
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Q2. What matters to you when it comes to Care at Home Key themes in this question were recovery support, early intervention and prevention to prevent crisis and long term dependency. You would like staff to be better aware of this approach. You want us to provide both practical and information support for carers. You want person centred care and you want a well trained workforce with technology supporting the workforce and not replacing it. You want community and connection with people enabled to stay active. Q3. What could be the impacts of introducing a Care at Home threshold? Feedback identified both positive and negative impacts, alongside impacts that may be considered neutral but still important to consider. Positive • Having a clear policy and guidance in place may help avoid a postcode lottery of care provision: fair and transparent procedures are essential across Argyll and Bute. • Will help to mean access to Care at Home is given to more people that need it. • Gives a clear opportunity for review when threshold is met – is Care at Home the best fit for the individual or is a residential care home more appropriate? • Gives unpaid carers the opportunity to voice concerns they have about supported loved ones at home with high levels of care – ‘allowing’ this conversation to happen. • Recognition that residential care is not a negative option for an individual, especially when care needs are exceptionally high. • If coupled with other improvements (e.g. aftercare and financial support help people stay at home longer. Neutral (i.e. positivity or negativity unclear but important to consider) • Day services may become more critical if home care is reduced – however this presents opportunity to transform/expand day care services. They currently only provide day respite care but is there potential to expand and provide care with basic needs, meals, social contact, games etc… • Need to compare costs and benefits of day care vs. residential care. Negative Wellbeing of person receiving care • Potential deterioration in physical and mental well-being of clients
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• Risk of poorer quality of care • Fear and anxiety about reaching the threshold and potential relocation. • Loss of independence and autonomy if moved into residential care. • Single individuals may find a 25-hour limit insufficient for their needs. Impact on unpaid Carers • Increased reliance on spouses and family members • Emotional and physical strain, especially for aging carers. • Risk of burnout, mental health decline, and financial insecurity. • Younger family members may be pressured into care roles, affecting employment and education. • Guilt and pressure on family members to step in and provide care without support or training Island and Rural Considerations • Displacement from local communities due to lack of nearby residential care. • Reduced family visits due to travel costs and unreliable ferry services. • Cultural and emotional disconnection from familiar environments. • Different islands need different solutions — a one-size-fits-all threshold may not work. • Local facilities (e.g. Thompson Court) may need upgrading to meet Care Inspectorate standards. • Insufficient care home beds Financial and Service Pressures • Uncertainty around who pays when the threshold is exceeded. • Travel costs for carers and families add financial strain. • Need for services beyond basic care, including companionship and mental wellbeing support. • Frequent reviews (every 4, 6, or 12 weeks) may strain care coordination teams. • Risk of delays or inconsistencies in reassessing needs, especially in remote areas. • Need to balance cost with dignity and quality of life.
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Employment, local economy and workforce impacts • Concern about future services and jobs – e.g. if care moves off-island, local care roles may diminish • WPS (Workforce Planning Services) may be more expensive and use more hours, increasing pressure on budgets and staff • Professionals may leave the sector if they feel unsupported or overburdened. • Highly trained staff may be underutilised or stretched thin Q4: What would be the impact of not introducing the Care at Home threshold? Several key themes were raised during discussion: Service demand and pressure including greater use on inpatient beds, unpaid carers may have increased role without formal review, workforce leave due to high workload and lack of support particularly in complex tasks. Task led care lacks emotional and social support. You told us we needed integrated teams who could be better coordinated to deliver care. You wanted us to invest in local authority carers and look at alternative service models to supplement current care structures. You asked us if current services such as Technology Enabled Care or day services were underutilised. You told us communication and access were important to allow families to navigate the system effectively. Q5. Further Thoughts on Care at Home and Threshold Proposals You want better infrastructure and innovation, you want a focus on workforce, you want compassionate care models and consistent quality of care across providers. Travel is an issue should your loved one be moved out of area for care both in infrastructure and funding. You want clarity about what happens when people are assessed above 25 hours of care and you want to know what contingency plans are in place. You want fair access regardless of geography or financial status. You would like digital literacy barriers addressed in accessing support. You want to ensure local alternatives are in place before implementing thresholds. The online response We provided an online questionnaire to support a written response or for those who were unable to attend. The questions are outlined below.
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Who visited the online hub? The image below highlights that 1224 unique visitors visited the online consultation, 219 people completed the survey at least once or asked a question. There were a total 1612 visits by the public. Figure 1 Based on how people interacted with the online hub we can tell how engaged they were with the consultation. The majority had their awareness raised, 43% were informed and 16% engaged. We asked for demographic information but only 6 people provided their details and could be identifiable so we will not publish this data in the report. However people were asked to identify which locality they were responding from. Figure 2
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Figure 3 The pie chart in Figure 3 provides the percentage breakdown of respondents including those responding from out of area. Figure 4 Most respondents identified as unpaid carers in Figure 4 with other contributions from all identified stakeholder groups. Care providers chose to submit their feedback via the online questionnaire.
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Figure 5 We asked where you lived as some of our localities can have islands, urban and remote mainland. Most respondents (41.8%) were from mainland followed by island communities (34.6%). Figure 6 Most respondents (105) disagreed with the premise that the proposal would increase fair access to care. However 75 respondents were either neutral or agreed with the proposal. 50 respondents somewhat disagreed.
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Figure 7 Similarly when asked if the threshold of care was a good decision from everyone in Argyll & Bute 115 respondents definitely disagreed , 67 were neutral or agreed, 51 somewhat disagreed Both narrative questions elicited strong support for the development of residential care on Bute. This was also reflected in the face to face consultation. A number of responses have shared their personal stories of caring for their loved ones or being cared for. There is a substantial theme on the possibility of residential care and care outwith the area for a loved one. You also asked if this would impact across other parts of our health and social care system. Written Survey Response Every narrative response has been read and we have drawn out a range of themes and some comments which illustrate this Q6 We asked you can you tell us how the proposal will affect you or someone you care for now or in the future The sentiment summary gives us a broad indication of how people have responded which has some correlation with question 4 in respect of whether people have confidence in
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the proposal. The summary notes that 46% did not provide a favourable response, 11% were neutral and the rest were mixed or in agreement. While there were similar themes identified as there were at the in person meeting, the responses were more skewed to disagreement. You felt the proposal was ‘binary’ or ‘arbitrary’, which was not the intention however we did require to communicate that residential care may require to be an option for very high care needs that we are unable to address without limit in the community. This is also likely to reflect the lack of opportunity for discussion presented by survey response which was opened up through the in person consultation. “I agree that we need to look at how/why/when we deliver care at home but this ceiling feels very arbitrary” The potential for out of area/off island residential care was a primary theme for respondents alongside the potential impact on unpaid carers and the impact on older adults. It is important to note that in delivering this consultation we had to acknowledge that residential care may be an option if we were unable to review and plan your care in the community. A contributing factor of this would be available workforce and available budget. We are grateful for the skill and commitment of agency staff who work in Argyll & Bute however premium priced workforce is not a sustainable approach in the long term and often does not offer the continuity that families/individuals would like in the care received. [the proposal] “Needs change, and the burden of care will land on families. What happens to those without families nearby. These proposals will inevitably lead to our most vulnerable living with massively increased risk, the pressure on emergency services will increase, and ultimately mortality will increase” “it disproportionately affects elderly people whom often have multiple comorbidities which often require more intensive community care. In addition, there are such variety of needs that some people will not need as much as 25 hours, others will need more” “it can feel unfair doing the same job for less wages” The inequity faced by island communities was highlighted alongside a reflection on funding provision: “Local authorities healthcare partnerships and central government need to increase year on year the investment into social care provision to meet demand rather than restrict access to accommodate budget constraints. Island communities already suffer from poorer provision across a whole range of services and this proposal will increase the inequalities felt by island communities.” There were concerns on the emotional impact on both the cared for and their loved ones, this reflects the comments from the in person consultation on the role of community in caring for someone.
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“loss of contact with local community, splitting families and friends, social isolation both for the individual accessing care and support and for those left behind, and research supports the fact that fewer people thrive in residential care than in home delivered care” We all benefit greatly from exceptional staff who work with individuals and families to support the delivery of care. They told us that relationship was important and they did not want to damage it. It’s important to note that the consultation did not identify a “cap” but a point of review where if your assessed need went beyond a number of hours that supported fair access to care we would provide a route to review and plan your care. “To put clients and that of assessing professionals in the position of not being able to offer staying at home with a care package due to a 'cap on funded hours' will be very upsetting and damaging to the relationships between clients and allocated workers. As a worker what would be the point in assessing if we cannot provide the personal outcomes?” We had further responses from staff in respect of our financial challenge. We have noted that we anticipate the need in Argyll and Bute to increase, and we forecast that some of the people receiving care will have care needs that develop – so we anticipate that there are those who don’t need this level of care yet but may in future. Our care at home redesign must address the holistic nature of care delivery in our communities and ensure that people remain well for as long as possible – this means people with moderate care needs to reable them need care too. We would anticipate that the policy has a longer term impact in how we deliver care alongside other measures. “I work with many people who access care at home. I can understand the thinking behind this proposal but struggle to see how the savings from this will be enough to improve care provision in my local area. If only 6% of people receive over 25 hours of care a week how can the savings from this impact all of the people waiting on new packages or an increase in their care.” Similarly to the in person consultation you asked where else in the system would be affected. As noted care at home provides a key role in the overall access to care both in people returning from acute care in NHS Greater Glasgow and Clyde and from our General and Community Hospitals. We have innovative services offering Hospital at Home in Oban and Virtual Ward which allows you to come home if you can be cared for. We will continue to develop our integrated approach to deliver care to ensure our model for care at home adapts to our populations needs. “staying independent in one’s own home is a key strategy to keeping the population from overburdening the hospitals and care centres and generally gives better patient outcomes.” Unpaid carers have rights in legislation; we will take into consideration your needs and we are planning for future needs through our overall strategic planning. However our
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services may look different as we require to work within the available resource and this needs to be considered as part of a whole system approach with wider partners. “This will mean that my ability to work will become limited/stop - I will become another member of your aging, non working workforce before I need to.” “We are well below this 25 hours per week threshold at the moment so little effect just now. How the future demands will grow is a pure guess but grow it will. However 25 hours a week should be sufficient at 3.6 hours a day....but I m no expert just an unpaid carer!” We heard from staff who are currently delivering services “Anything over 25 hours and, importantly, are double visits, need to have a threshold. I am an ex community carer and spent 30+ hours a week with other carers providing care for a number of folk. Once people are highly dependent it isn’t appropriate for community care. There are no staff, equipment is often denied and you could use that time to see several single, lower input people. It’s not doable” You showed us an awareness that even in distributing care in a fairer way we still have work to do in how we approach our workforce and commissioned care. “This cap will initially free up care at home hours, but yet I have seen no mention of how the council will also aim to stimulate the care provider sector” You have provided significant challenge on our modelling of care at home and highlight what we have identified in terms of our Integrated Impact Assessment – care at home services are primarily utilised by older adults and we are aware of our older adult unpaid caring population. We welcome the opportunity to work with our partners in exploring high quality community based support and a better understanding and utilisation of Self Directed Support. We will follow this up as one of our supplementary actions and ensure we provide assurance that assessment will remain person centred. It is important that residential care is not viewed negatively and can be the best option of care where assessed and offer a wonderful environment supported by excellent staff. “However, the proposal made by the HSCP does not align with the SDS Values and Principles, Human Rights legislation, the SDS Standards, the statutory duties within SDS legislation, the UN Convention on the Rights of Persons with Disabilities, or the Equality Act. It will disproportionately affect older adults and therefore raises serious concerns about age discrimination. Suggesting residential care as an alternative is inappropriate, especially when investment in high-quality community- based support has not been fully explored. The proposal is not person-centred. There is ample evidence that "time and task" models of care are not effective in supporting people meaningfully, nor do they result in cost savings.”
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“The person I care for would actually benefit from residential care. They are living with advanced dementia. It is very challenging to give just basic care needs. The only visitors they have are carers. Families seem to have a reluctance to seek residential care” We are aware that there are beneficial funds that must meet a threshold of community care and we will ensure that staff work with individuals to maximise income. “We are trying to apply for Independent Living Fund. To do this, we need to meet the threshold of £800 carers a week, which 25hours of LA care would just meet. However if all care is being provided by PAs, the cost of which is halved for 25 hours would mean the threshold would Not be met.” Care is provided as contact hours e.g. 25, travel is incorporated in contractual arrangements with care providers. “Do you include travel time in the 25 hours? That could make a big difference.” Q7 Please use this space to tell us anything that we may have missed or any or feedback or suggestions you have on the proposal In your summary comments the theme of residential care remained a priority. We would seek to better use the capacity we have in Argyll & Bute but as the ongoing Care Home review suggests we cannot fully address the need in area sustainably. Where we can, we would always seek to provide the choice for individuals but take cognisance of some of the needs of carers and families expressed. Bute was particularly mobilised in respect of the development of residential care on island. The are a number of reasons care may be delivered out of area, sometimes to be closer to family sometimes if a particular type of care is required which is not available in Argyll & Bute or the caring situation is no longer sustainable. We have included the availability of residential care in our integrated impact assessment . “I think it’s a good idea and might free up some availability for people on the waiting list for care. I’m not sure where the care home places will come from though as I thought there was usually a waiting list for those too” “This needs a full impact assessment on the availability of residential care to meet the change in demand across Argyll and Bute. This needs to be place based to ensure resident populations are not shipped off out of the area”.
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Your responses in summary also reflected some of the things we wanted to communicate with you and if you thought the proposal was fair. “Considering the wider picture, how difficult it already is to provide care packages this seems like the only way forward. The general public have been sheltered from the effects of decreasing budgets for fifteen years. The council has been asked to provide more with less money year after year. People need to understand that this is what we are left with.” “Think the proposal is fair and equitable as currently some areas with no care and other areas with plenty of care so to give parity across the areas is much better.” “Family members must help provide care for their relative. They could be going in a couple of meal times.” You provided us with response that will support our next steps and our Care at Home redesign: “Over the last 10 years the world of social care has changed beyond recognition but this proposal and the care system involved seems outdated and no longer fit for purpose. Social Care Futures has done extensive research and consultation on new models of care, there are international case studies on shared lives, ‘at home instead’ and other inter-generational care models, allocation of personal budgets to allow free choice of care and the increased use of digital technology, technology enabled care and investment in more flexible social care models and staff would all mitigate this binary proposal. To provide future-proofed social care over the next 25 years to cope with the increased demand for care it is investment and not budgetary cuts that is needed” “Could we have a volunteer system like the Mid Argyll Transport Volunteers who could take the place of paid carers for those needing less care…or making a sandwich for lunch. That would leave the professional carers more time for the more significant needs” You reflected back the importance not only of equal access but equity – professionals undertake a holistic assessment that looks at all the assets you have in your life. “Equal access is valuable, but equity—providing the right support based on personal circumstances—is essential. Introducing a 25-hour baseline may help to simplify and standardise care provision… and rigid thresholds could overlook the complexity and variation in personal care needs. Professional judgement must remain central to the care assessment process.” You were reflective on where we have shifted the balance of care hospital to our community dementia team “It is difficult to see where monies saved on inpatient services e.g. Knapdale ward (MACHICC) have been used to increase community care. I think the HSCP need to look at the budget available and prioritise the needs of our community.”
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You asked us to ensure that we follow up on any changes and monitor how it will work ensuring it is flexible and person centred. You want us to be bolder with change. “flexibility and person-centred care must remain at the core of any new policy. While thresholds can support planning and consistency, clear guidelines for exceptions and discretion should be built in. It’s also critical to monitor how this change impacts both staff and service users in practice. I strongly recommend a structured review period following implementation, with regular feedback loops to ensure the policy remains responsive and effective” “it’s become unsustainable… you need some upper, and lower, limits. I’ve been in to people just to administer drops in eyes and take stockings off when family are there” “I think Argyll and Bute Council needs to be bold and creative such as implementing Circles of Support discussions within the community. The council need to consider how small numbers of people with care needs, living in close proximity may be able to pool budgets in order to share personal assistants, or care providers…it is not creative. Be bold now, and buck the trend of short-termism” A number of you shared experiences that were positive, negative and personal and we thank you for doing this. “You know, it’s difficult being old. We don’t think of it when we are younger, but we slow down, we don’t have the same quality of life, we can't do what we want to do,. We become less independent….like having to give up our car. We can’t see books or newspapers any more…..or the tiny print on this form! Our legs won’t take us as far as the shops. The wee jobs around the house like putting a battery in the fire alarm beat us….we are scared of falling off steps. We get sadder as we lose the people we love. We have less money but need to buy more things to help us through life. But inside we are the same as we were 50 years ago. Please don’t even think of dumping us in to a care home if we don’t want that and there is another way of looking after us” 6. Professional response We met with Service Managers, Adult Services Social Work Team Leads, Occupational Therapy(OT) Team Leads, Carers Representatives and Care Providers. With staff we had facilitated discussion with managers and with the professions. Assessment of need is primarily a multi-disciplinary approach. The regulatory responsibility for social work and social care is the councils with services delegated to the IJB to be delivered in partnership. We were challenged by our social work team leads in respect of their professional practice and the legality of our approach. Due diligence in approach had been researched prior to the consultation and the Chief Social Work Officer responded to the social work
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team leads response formally. The challenge received was welcome and provides rigour in testing approach noting the duty to assess with provision within available resource. The environment our SW teams are working in is challenging in respect of need and resource; they are professionally bound to assess by need however that need does require to take account of our capacity to deliver the service. Our teams are the direct contact with those requiring service and their families. Within the care group people often come to us in crisis having to navigate a new situation, they may have become carers or realised they are carers and our professional staff and social care staff support this period of change. OT responded that the lack of available care at home and pressure from families to discharge is very difficult and reflected that they would like better internal communication. They noted pressure on internal services to make up the shortfall in available care which subsequently prevents them undertaking reablement. While not new this becomes increasingly problematic as need rises and in budget resource decreases noting care at home packages with no end point (care may not necessarily be permanent). Occupational Therapists also assess within their profession to the need rather than the resource. They noted the impact on carers within the system of care and that often it is crisis point before carers request assistance. They noted that there are people cared for in community where it would be more appropriate and dignified to be cared for in a 24 hour setting. Multi-disciplinary teams may assess for 24 hours care and families will uphold the wishes of a loved one and ask for a further assessment to bring them home despite the fact this may not be in the best interests of the individual. They also query how need assessed over a threshold would be monitored and measured and where the professional liability lay. Telecare submitted a response noting the potential risk of misuse of telecare where there may be a support need and the employ of the responder service to meet a social/practical need. Care providers submitted their responses through the survey and only a single provider responded by name. As such we mainly included excerpts from the survey response in the body of the text response but note the points made below: • The proposal undermines fair access • The proposal is not person centred • Risk of institutionalisation • Contradiction with local and national policy • Lack of consideration for remote and island communities.
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7. Our findings What do the findings mean? We would like to thank all of the community members who attended in person and the 232 people who responded online with all 406 written responses. We would like to thank our staff and partner providers who have provided a rich and valuable insight which we have sought to represent within the collection of responses and provides a springboard for further partnership. We had a reasonably balanced geographical response noting slightly less response in Helensburgh and Lomond where we tend to have more available staff resource. A key theme identified across the responses was the desire to maintain a person centred approach. Choice and access to care were reflected. We would agree that access to care is not equitable across our geography and remains a priority and choice of care requires to be improved through a better knowledge of self-directed support and in supporting providers/workforce who can support the delivery of this and in the further planning of care models through the care at home redesign. There was a call for investment, however we are working in a resource bound environment in social care at present. We have provided clear financial modelling within the recommendations to ensure there is an understanding of the funding available. We are unable to consider changes in any service area or with any care group across our integrated system without reference to the financial position. The feedback highlights significant concerns about equity, sustainability, and the emotional and practical impacts of the proposed changes. Many online respondents focussed on the potential for residential and out of area residential care. This report highlights that residential care should not be viewed negatively. We are proud of our caring staff in our care homes and all they do to create a homely environment for our adults who require 24 hour care and in supporting their families. Bute had a strong voice in respect of a residential care need. Carers also fed back that they saw the opportunity to have a threshold of care as an opportunity to discuss whether their loved one remained at home – a conversation that can be difficult and often not initiated by the carer. There is a clear preference for maintaining and enhancing home-based care, alongside calls for increased investment and support for both professional and informal carers. However we also take cognisance that in some instances 24 hour care is considered by professionals to be in the best interests of the person. We recognise that the primary care group using care at home are our older adults and any change would have an impact on them. We would monitor any change with the IJB to ensure that services are safe and care quality is not impacted.
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Our care professionals are concerned they will not be able to undertake their role in accordance with their professions guidance and in policy and legislation and that their may be resulting relationship damage with service users and families. We have undertaken due diligence in respect of ensuring the safety of any potential decision by the IJB as advised by the chief social work officer. However we understand that we need to continue to work with staff and monitor any potential impacts and mitigate risk during any change operational or policy. We have in the context of response provided financial modelling to the IJB to explore what different thresholds of care informed by the response and in reference to the financial position. The largest risk in the introduction of any change remains the potential for increased impact of those providing unpaid care however we would reflect that the number is people impacted would be low and allow us to manage this. Unpaid care already has the risk of breakdown of care in the community with many carers not presenting until they are in crisis. The review of care and developing need is key to supporting unpaid carers and maintaining their rights. We have had reflected different issues in different communities and the challenge of geography, workforce and need. We have outlined the impact on our wider system if we are unable to address the core requirement of social care and we are required to do this within the budget available. 8. Recommendations The recommendation on balance is for the policy of a threshold of care to be introduced however we would request that this should be reviewed on an annual basis by the IJB in the wider context of our care environment. The initial threshold was proposed at 25 hours, however on balance of evidence we would propose a threshold of 28 hours with the accompanying context below: 1. Clarify and Communicate the Proposal Communicate and clearly explain that the threshold is a review point, not a hard cap. 2. Strengthen Community-Based and Flexible Care Models We are investing in reablement services and early intervention to reduce long-term dependency through our whole system process review in 2025-26. This process will begin and require some time to embed. • We have a planned review of day services • We will internally audit care plans to ensure they include non-social care elements (e.g. community groups, informal supports).
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3. Address Equity and Island-Specific Needs • Develop localised solutions for island and rural communities through the carte at home review. • Review Care Home provision and local facilities to reduce displacement where possible. • Ensure fair access regardless of geography or financial status. 4. Support and Sustain the Workforce • Pay and conditions for care staff, including agency workers are often set rates however we will try through our commissioning review to ensure that we achieve as much consistency as possible across providers. We commit to minimising agency usage as far as possible, only utilising in cases of critical service pressure or regulated staffing levels • We will support investment in training, career pathways, and retention strategies through workforce planning. • Promote continuity of care by reducing reliance on short-term agency staffing. • Update arrangements for social work governance to ensure consistency of practice and support for professional decision-making within a clear policy context. 5. Support for Unpaid Carers • Improve signposting to services and carers’ rights including financial advice. • Include carers in care planning discussions and strategic decisions. 6. Improve Infrastructure and Digital Access • Address digital literacy barriers to accessing care and support – we may look outward to partners for support with this. • Invest in technology-enabled care that supports human care. • Ensure transport and connectivity are considered in care planning, especially for remote areas through better scheduling. 7. Strengthen Integrated and Preventative Care • Develop Hospital at Home and Virtual Ward models. • Improve multi-disciplinary coordination, including GP involvement. • Ensure regular reviews and holistic assessments are built into care pathways. 8. Monitor and Evaluate Impact • Establish a feedback loop to monitor the impact of any threshold policy.
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• Track outcomes for individuals, carers, and staff. • Use data to adjust policy and ensure it meets evolving needs. 9. Next Steps • The findings in this report will be presented for scrutiny to the Finance and Policy Committee on 16th September and subsequently to the Integration Joint Board on 17 September noting that papers are available publicly on 10th September. • The Finance and Policy Committee will be asked to make a recommendation to the IJB • The IJB will be asked to consider the recommendation of proceeding with a threshold of care noting that this must reference the consultation report and the available resource at the public meeting. If the IJB accept the policy proposal this will then be implemented. If it is not accepted the IJB will direct officers for revisions or alternative action.
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10. Appendices Survey questions and documentation can be accessed at the following link to the engagement hub https://nhsh.uk.engagementhq.com/argyll-and-bute-hscp-threshold-of-care-policy- consultation In person summary response. Q1. What does good Care at Home look like? Core Principles • Care should be rooted in dignity, respect, and person-centred values. • Support must reflect what matters to the individual, not just what is clinically necessary although recognition that wider support systems can play a role here. • Staff should be well-paid to ensure reliability and retention. • Protocols should be in place for service disruptions or provider changes. • Ensure local provision of residential care where needed. Carer Qualities & Support • Carers should be friendly, patient, good communicators, able to build rapport with families, and take pride in their role. • They must be well-trained in personal care, medication, and awareness of wider health and wellbeing, e.g. mental health awareness. • Fair pay, supervision, and ongoing training are essential for retention and quality. • Consistency of staff came through strongly as key to building trust and continuity. Time & Quality • Short visits (e.g., 15 minutes) are often inadequate to ensure dignity and meaningful care. • Care should be flexible and responsive, not task-driven or rushed. This requires training and supervision to be able to deliver safe and effective care within time constraints - Time constraints must not compromise individualised care. • Flexibility around routines like waking and bedtime. Reviews and assessment of need • Reablement should be the starting point for care, with regular reviews and multidisciplinary input – support independence through short-term, goal oriented care (where appropriate)
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• Accurate assessment of needs is vital to ensure decent support. • All clients should receive a reablement assessment before social work referral. • Reablement should be the first step in care provision. • Multidisciplinary input could include health, social care and potentially third sector partners. • Regular reviews of care packages are important for fairness, quality, and resource use. Communication & Integration • Accurate, up-to-date care plans are essential. • Effective information sharing among carers, nurses, GPs, and other professionals improves coordination. • GP involvement in care planning is central. • Access to health records is important for joined-up care. Independence & Choice • Care should support independence and not reduce capacity. • People should have real choices, including staying at home. • Digital literacy and awareness of self-directed support options need improvement. Community & Local Solutions • Local services, volunteering, solutions and trusted relationships are vital. • Important for people to be aware of what other support is available locally, outside of Care at Home. • Keeping care local (e.g., on islands) matters and supports wellbeing and continuity. • Clear support channels are needed for individuals without informal networks. • Need for clear, accessible information (e.g. a booklet or directory) about available services. • Support for carers: Including befriending services, advocacy, and early welfare advice. Q2. What matters to you when it comes to Care at Home Care at Home & Recovery Support
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• The right carer matters: someone trained, aware of individual needs, and consistent. • Early explanation of care options is essential, especially for short-term recovery support. • Convalescent/short-term care homes could be explored as part of recovery pathways. • Preference for non-institutional care with alternative residential models. • Early Intervention & Prevention • Early support helps prevent crisis and long-term dependency. • Social work staff need thorough training and awareness to support proactive care. • Systemic stress and fear can hinder early intervention. Support for Carers • Recognition of the burden on unpaid carers and the need for practical support, not just information. • Importance of respite care and acknowledging carers’ need for rest and recovery. • Relevance of Carers (Scotland) Act, and Social Work (Scotland) Act in shaping support Person-Centred Care • Care should fit around the person’s needs. • Emphasis on independence, flexibility, and personalised approaches. • Continuity of care and trusted relationships are essential. Workforce & Training • Recruitment should focus on values as well as skills. • Training should cover diverse situations and respectful communication. • Fair terms and conditions, including travel costs and wellbeing support, are important. Technology-Enabled Care • Technology should support independence, not replace human connection. • Accessibility and clear support processes are needed. • Must be cost-effective and value for money, but also value for dignity. Community & Connection
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• Intergenerational interaction and community engagement are vital. • Support for volunteering and staying active. • Care should help people stay at home and stay connected.
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Q3. What could be the impacts of introducing a Care at Home threshold? Feedback identified both positive and negative impacts, alongside impacts that may be considered neutral but still important to consider. Positive • Having a clear policy and guidance in place may help avoid a postcode lottery of care provision: fair and transparent procedures are essential across Argyll and Bute. • Will help to mean access to Care at Home is given to more people that need it. • Gives a clear opportunity for review when threshold is met – is Care at Home the best fit for the individual or is a residential care home more appropriate? • Gives unpaid carers the opportunity to voice concerns they have about supported loved ones at home with high levels of care – ‘allowing’ this conversation to happen. • Recognition that residential care is not a negative option, especially when care needs exceed 24 hours. • If coupled with other improvements (e.g. Aftercare and financial support help people stay at home longer. Neutral (i.e. positivity or negativity unclear but important to consider) • Day services may become more critical if home care is reduced – however this presents opportunity to transform/expand day care services. They currently only provide day respite care but is there potential to expand and provide care with basic needs, meals, social contact, games etc… • Need to compare costs and benefits of day care vs. residential care. Negative Wellbeing of person receiving care • Potential deterioration in physical and mental well-being of clients • Risk of poorer quality of care • Fear and anxiety about reaching the threshold and potential relocation. • Loss of independence and autonomy if moved into residential care. • Single individuals may find a 25-hour limit insufficient for their needs. Impact on unpaid Carers • Increased reliance on spouses and family members • Emotional and physical strain, especially for aging carers.
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• Risk of burnout, mental health decline, and financial insecurity. • Younger family members may be pressured into care roles, affecting employment and education. • Guilt and pressure on family members to step in and provide care without support or training Island and Rural Considerations • Displacement from local communities due to lack of nearby residential care. • Reduced family visits due to travel costs and unreliable ferry services. • Cultural and emotional disconnection from familiar environments. • Different islands need different solutions — a one-size-fits-all threshold may not work. • Local facilities (e.g. Thompson Court) may need upgrading to meet Care Inspectorate standards. • Insufficient care home beds Financial and Service Pressures • Uncertainty around who pays when the threshold is exceeded. • Travel costs for carers and families add financial strain. • Need for services beyond basic care, including companionship and mental wellbeing support. • Frequent reviews (every 4, 6, or 12 weeks) may strain care coordination teams. • Risk of delays or inconsistencies in reassessing needs, especially in remote areas. • Need to balance cost with dignity and quality of life. Employment, local economy and workforce impacts • Concern about future services and jobs – e.g. if care moves off-island, local care roles may diminish • WPS (Workforce Planning Services) may be more expensive and use more hours, increasing pressure on budgets and staff • Professionals may leave the sector if they feel unsupported or overburdened. • Highly trained staff may be underutilised or stretched thin .
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Q4: What would be the impact of not introducing the Care at Home threshold? Service Demand and Pressure • Continued strain on services due to rising demand and limited resources. • Increased use of inpatient beds and greater pressure on district nurses, occupational therapists, physiotherapists, and mental health services. • Families and spouses may face additional caregiving responsibilities without formal support or review. • Without change, services may become unsustainable due to rising demand and limited resources. • Highly trained staff may leave if workloads remain high and support is lacking. Concerns About Current Care Models • Task-led care lacks emotional and social support. • Unsupervised or unfamiliar staff may deliver impersonal care, leading to dissatisfaction and distress. • Unpaid carers are expected to perform complex tasks without adequate training or support. • The current model leads to dissatisfaction among relatives and those being cared for. Need for Integrated Teams • A bottom-up, team-based approach is needed to improve outcomes and reduce pressure. • Better coordination and integration across services would support both clients and staff. Resource Allocation and Staffing • High spending on agency staff is questioned. • Investing in local authority carers with better pay and conditions is seen as more sustainable. • Alternative service models (e.g., OSIS or sitter services) could supplement current care structures. Missed opportunities for Investment • Maintaining a stable system could attract public/private partnerships. • Potential to develop or upgrade local care facilities (e.g., Thomson Court). • Technology-enabled care and day services could be underutilised.
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Flexible models tailored to different islands may not be explored. Infrastructure and Equity Issues • Facilities may not meet regulatory standards without investment. • Under-65s with complex needs may continue to lack appropriate residential options. • Families may face inequities in access, especially where informal carers are expected to fill gaps. • Rising care costs without strategic planning could burden both public budgets and families. Strategic Considerations • Need to balance investment across care at home, residential care, and day services. • Contingency planning is essential to avoid forced relocation and maintain community ties. • Self-funding options raise concerns about inequality. • Travel time and geographical challenges affect care delivery and allocation. Communication and Access • Clear, accessible information about care at home and home help services is needed. • Families need guidance and transparency to navigate the system effectively. 5. Further Thoughts on Care at Home and Threshold Proposals Infrastructure Needs • More facilities are needed for assisted living, care homes, sheltered housing, and hospital-at-home services. A wider range of services needed but also ones that meet the rural needs of Argyll and Bute. Innovation. • Upgrades to existing facilities (e.g. Thomson Court) are essential to meet regulatory standards. Workforce Development • Increased funding is needed to recruit and retain care-at-home staff. • Improved working conditions and wages would make caring a more attractive career. • This is a career which should be valued and paid accordingly. • Carers should have a voice in shaping services and policies.
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• Face-to-face training is preferred over online formats to ensure quality. Care Model Concerns • Current care models are often process-driven and lack compassion. • 15-minute visits are inadequate and do not meet real needs. • Care cancellations (e.g. after A&E attendance) raise concerns about continuity. • Quality of care varies, especially in the private sector, where training and supervision may be lacking. Carer Allocation and Criteria • Lack of clarity around when one or two carers are required. • The job is increasingly difficult due to an ageing population and rural geography. • The 25-hour cap is seen as a financial limit, not a reflection of actual need. Technology and Equipment • Telecare is valuable but must be backed by responsive human support. • Equipment re-use and access to stores remain unresolved. • The Jeannie Deans Unit is viewed as a model of good practice. Integration and System Challenges • Health and social care integration remains incomplete. • Poor information sharing between services leads to gaps in care. • A single point of contact is needed but must be effective. • Top-down NHS approaches limit local flexibility. Funding, SDS, and Third Sector Role • SDS (Self-Directed Support) needs clearer communication and transparency. • Third sector organisations are responsive and essential but underutilised in planning. • Excessive agency care costs could be reduced through better use of SDS. • Third sector can identify needs early and act quickly. • Potential for community networks, volunteers, and intergenerational initiatives to fill gaps. Residential and Respite Options • Not everyone wants to stay at home—alternative options should be discussed earlier.
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• More residential and respite options are needed, especially in rural areas. Feedback and Person-Centred Care • People may be reluctant to complain—safe, visible feedback channels are needed. • Care planning should be based on what matters to individuals. Threshold-Related Questions and Concerns • Uncertainty about what happens when someone reaches the 25-hour threshold. • Messaging around exemptions and flexibility is unclear. • Palliative care exemptions must be protected. • Contingency plans are needed for those exceeding the threshold. • Financial pressure should not override personal choice to stay at home. Travel and Accessibility • Travel to care homes, especially across water, is difficult and costly. • Cheaper ferry tickets could support family visits and continuity of care. • Funding for travel is a barrier to maintaining connections. Equity and Strategic Planning • Consider top-up options via benefits for those unable to self-fund. • Ensure fair access regardless of geography or financial status. • Improve transparency and communication around care planning. • Recognise and support unpaid carers, who are essential but undervalued. • Address digital literacy barriers to accessing support. • Explore befriending and advocacy services to reduce isolation. • Ensure local care alternatives are in place before implementing thresholds. • Concerns about money being spend in wrong places- Investment should focus on humanity, not just infrastructure (e.g., “bikes vs beds” or “roads vs care”). • Investment should prioritise human-centred care over infrastructure.