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Rethinking health and care

From Civil society Scotland Wiki

Introduction[edit | edit source]

Health and social care is about people and their lives. Scotland therefore needs its whole system of support services to work together with people at the centre.

This is because many public services and community supports interact within a wider system to achieve a healthy, fairer Scotland. We need to assess not only the parts of the system that are delivered or ‘owned’ by the Scottish Government but broader community-based support, self-directed support and the role of organisations that people set up to deliver solutions that prevent people reaching the stage of acute needs.

The Sustainable Development Goals and National Outcomes reflect well the various elements of this eco-system and provide a good starting point to broaden the scope of health and social care interventions. As part of this, third sector has a key role to play in delivering a human rights-based approach to increasing participation, securing transparency and enhancing accountability of health and care in Scotland.

The new National Health and Care Standards provide a good basis for that rights-based approach. But standards are not rights. If we are to be a country that genuinely focuses on rights, we need to ensure that people are by default in control of their own health and care support.


Aims and strategy[edit | edit source]

The voluntary sector needs to refresh its strategy for engaging health and social care support for people.​

Our aims ought to be to:

  1. Develop an alternative whole-systems approach to commissioning that delivers for people and communities, by focusing on their strengths and assets, rather than their weaknesses
  2. Use the National Performance Framework (and SDGs) to secure the human rights, empowerment and wellbeing of people, their families and communities over and above than the needs of existing institutions or systems.
  3. Also, challenge the third sector to hold a mirror up to itself and consider how we are genuinely values-based and fit for purpose to deliver a dignified and rights-based health and care service in the 21st century.

In order to meet these aims, we should take the following approach:

  1. Bring into the light the evidence and data available on the different outcomes achieved when shifting from a medical approach to treating problems to a social approach to healthy and fulfilling living
  2. Secure greater participation for people and their carers in decisions on how resources can be better distributed amongst those who require acute care, those who require support and those who can live independently
  3. Establish in our sector and campaign in other sectors for clearer lines of accountability for health and care spend, including to people who receive care and support.


Analysis[edit | edit source]

Objective Analysis Resources
Starting with people and communities How can we support people to take control of their own health and social care outcomes? How can we reduce their need for acute services?

Audit Scotland's report into self-directed support in 2018 found that almost £70m has been committed by Scottish Government to support implementation. It was also estimated that at least 53,000 people have chosen an SDS option. Audit Scotland found that, despite positive examples and some progress, "there is no evidence that authorities have yet made the transformation required to fully implement the SDS strategy".


Life expectancy in Scotland is increasing, but it isn't increasing equally for all and life expectancy is particularly marked by deprivation. Heath care policy cannot operate in a vacuum and indeed health care is not the main detriment of health. Socio-economic conditions and environmental concerns have a large role to play. In this way, a whole-system approach is necessary which therefore pulls-in third sector organisations not operating specifically in the healthcare sphere.

As part of the Health and Social Care Delivery Plan, local joint public health partnerships and a new agency Public Health Scotland, will be set-up by 2020 between local authorities, NHS Scotland and others to drive national public health priorities and adapt them to local contexts across the whole of Scotland.


There are also an, ever-growing, range of Scottish Government strategic, advisory and delivery groups focusing on varied issues. How best does the third sector interact with these groups in order to display the specific potential of the third sector, maintain independence and also keeping afoot of Scottish Government priorities and plans?


Community-directed support - See our theory, case studies and recommendations for a community directed approach to health and care support

How our sector makes a difference​​​ Third sector organisations are already heavily involved with initiatives that aim to encourage healthier lifestyles in Scotland, ultimately focusing on preventing future demand on health and social care services. Evaluation support Scotland found that the success of the third sector work in this area is 'frequently due to a flexible structure, often attributable to the involvement of volunteers in organising services delivery'. The ability to change and innovate to meet local needs and preferences is also essential in encouraging communities to see benefits of healthier living. The third sector's role covers health protection, health improvement and health intelligence. "There is an evidence base which demonstrates that volunteers are making a significant contribution towards services delivery in Scotland. Close ties between third sector organisations, communities and volunteers have facilitated the initiation and organisation of this informal service provision." Ref. Evaluation Support Scotland


However, the NHS health system has not prioritised handing over control over health and care outcomes to people. The preventative spend approach recommended by the Christie Commission in 2011 has not taken hold. As these are their unique selling point, the third sector remains peripheral rather than embedded in the health and care support system.

Our sector plays the following roles (Source: Evaluation Support Scotland 2019)​​​
  • Have knowledge and expertise of particular issues / communities
  • Help people to connect to and use parts of the health and social care system
  • Give people a voice
  • Provide services that are more responsive to needs (eg community transport)
  • Provide practical support: ‘that little bit of help’
  • Provide social activities
  • Help people stay healthy & active / maintain wellbeing
  • Focus more on prevention than cure


The power of data Are we looking at the right data? Official data has very narrow view of the contribution of third sector bodies focused on primary and secondary services, opportunity to improve the visibility of non-statutory resources so that within the purview of commissioners. A criticism of the Audit Scotland report was around a lack of accurate data, for example around the number of people choosing each of the self-directed support options. While Audit Scotland believed that data should have been developed earlier in the life of the strategy in order to measure the progress and impact of the strategy and legislation, there are other questions around whether we are looking at the right data in the context of health.


Social prescribing - community link workers are a positive step but can overburden under-resourced community-based voluntary organisations. Extensive third sector data that currently exists is invisible to the NHS and suggests an opportunity to connect these data sources to statutory platforms such as SOURCE and SPIRE. How do we connect people to local activities and services which support health and wellbeing through direct GP and primary provider social prescribing and digital health interventions.

A new Data Delivery Group is overseeing transformation of the way Scotland develops its strategy and governance around public sector data.


NHS Scotland Governance is under review –where will this be/focus in the future? Similarly, Scottish Government is currently revisiting information governance strategy as part of a broader data strategy for Scotland. This will bring data governance up to date with GDPR and digital rights. The NHS Information and Statistics function is going to be rationalised alongside a number of other functions such as technology-enabled care ​​within the new Public Health Body.

Developing a theory of change for a whole systems approach How can we ensure that people and communities are involved in the design and delivery of services? Link the health agenda to broader policy agendas such as inclusive economy, gender equality, education and tackling health inequalities. This should be framed through the Sustainable Development Goals, a strong, ready-made framework to think about cross-cutting issues, which is articulated in Scotland though the National Performance Framework.

We need better measures to improve transparency of information/manageability/simplification; improving resource/support to facilitate genuine engagement; supporting representation and advocacy roles with well organised/resourced feedback mechanisms; recognising the implications of short-term funding for community organisations; new financial pressures such as living wage and apprenticeship levy; opportunity for better recognition by some statutory organisations of the scale of the third and independent sectors, and their range, experience and expertise; the challenge for national providers to engage with 31 IJBs; supporting smaller local organisations and service users/carer networks to engage effectively


Engagement can be tokenistic or consultative rather than co-productive in many areas; engagement on specific issues when decisions have already been made – perceived lack of scope for change or influence; representation on IJBs is patchy and engagement with both IJBs and the SPG is high-level, while decisions are taken in other ‘operational fora’ where the third and independent sector are not present. Opportunities for better engagement (for third sector organisations and individuals receiving support) to achieve better outcomes. This includes participation in decisions that directly affect them - for example the chief medical officer has been pursuing the idea of realistic medicine which is essentially the right for people to choose quality of life over longevity.

The National Performance Framework, based on the Sustainable Development Goals (SDGs)​​ and Open Government offer a framework for a whole-systems approach
Workforce​ and skills Workforce development plans largely ignore the third and independent sectors, despite the fact that in some geographic areas or types of care, they are the majority of workers. This requires leadership on the changing nature of skills required, the challenges and opportunities of automation and engagement from enterprise and skills agencies on promoting health and social care careers.


Workforce needs remain a significant problem for self-directed support and the sustainability of social care more broadly too. The social care workforce is positive about the principles of personalisation and self-directed support. Nevertheless, a significant minority lack understanding or confidence about focusing on people's outcomes, or do not feel they have the power to make decisions with people about their support. Front-line staff who feel equipped, trusted and supported are better able to help people choose the best support for them.


Recruitment and retention remain well-documented problems for social care providers, across the private, public and third sector. Work has been done through the fair work convention to look at fair work in the context of social care, but perhaps there is more to be explored around the specific fair work offer of the third sector more broadly. Living wage commitments are a positive step, but there remain issues around sleepovers, and fair work should not be reduced to issues of pay alone. Working conditions are an important aspect and in this respect, here are issues for providers in delivering self-directed support, which requires flexibility, without putting increased pressure on social care staff.

There is an opportunity to develop re-skilling strategies as we move towards a more automated workforce. Could this be resourced by the Scottish National Investment Bank?


A broader discussion around workforce and skills in health and care that isn't just narrowly restricted to NHS employees.


Demographic changes and the changing nature of work could offer new ways to think about how we support volunteering, and the role this plays in community-based preventative support as well as enhancing well-being of those that volunteer.


Sustainability and resourcing The key to a sustainable health and care system is in prevention which lies outside the health and care system. However, the culture of the institutions involved (in all sectors) can work against this. The financial model for the health and care system is largely based on commissioning and procurement. It is focused on meeting targets and outputs within the system rather than thinking about the solutions that people and their communities need to prevent institutionalisation and enhance their wellbeing. This may work for buying medical supplies and hospital equipment, but not for securing health and care for people. We need to shift from buying and selling outcomes to investing in outcomes. The following developments in particular need more prioritisation:
  1. Civtech model - investing in supporting innovation and solutions, rather than buying outputs
  2. Local solutions - acceptance of different solutions in different areas built on top of fundamental human rights
  3. An investment approach - investing in community capacity - in particular grassroots preventative community-based supports
Public health reform One of the major interventions currently underway is a refocus on public health, as a core part of the health and care agenda. This involves the creation of a new special health board, Public Health Scotland, which will amalgamate public health, intelligence and health protection functions.

Much of the analysis presented above also applies to the Public Health reform agenda.

A more detailed analysis on Public Health Reform is provided in the Public Health Reform wiki page.


The following are specific areas that need further attention:

  • Governance of the new Public Health Scotland body needs to model a transparent, accountable and participative approach
  • Ensuring Public Health Reform takes a whole systems approach, including the system within which the voluntary sector operates
  • Ensuring the language used within the Public Health system matches the values and principles of people-centred service design


Considerations[edit | edit source]

Is continuing to increase funding to the NHS exponentially the right thing to do, even if it were sustainable? Should we start thinking about a broader health and care outcomes agenda instead? What would be lost as a result?

How can people and communities be equipped to promote their own wellbeing and meet their own needs?

If we are stuck with the Integration board / health and social care partnership model at least in the short to medium term, what can replace the current broken commissioning and procurement approach?

How can third sector representatives on Integration boards be better included, respected and heard? Should they be?

Can we level the playing field or change the competitive environment where collaboration is undermined by the need to compete for public sector contracts, favouring large-scale​ established organisations?

How can people working in social care and healthcare, whoever their employer is, be paid fairly and have decent working conditions?