Raising the standard of residential care

We need to put dignity and respect at the heart of the residential care system. That means better care for residents and supporting the workers who care for them.

I was in the Scottish Parliament today promoting UNISON's new Residential Care Charter. It follows on from our Ethical Care Charter, which has raised standards of care for people living in their own homes. UNISON’s residential care charter calls for:

• Time to care – to allow staff to properly care for the vulnerable people they look after
• Proper training and support for staff
• Decent pay for quality work
• Adopt measures to protect and support residents, including adequate staff ratios and thorough risk assessments

This summer the Scottish Government published new Health and Social Care Standards, which will be implemented April 2018. They set out what we should expect when using health, social care or social work services in Scotland. The Standards are underpinned by five principles: dignity and respect, compassion, be included, responsive care, and support and wellbeing. The principles themselves are not standards or outcomes but rather reflect the way that everyone should expect to be treated.

Now standards in glossy documents are fine, but what matters is how they are implemented. One of the standards states; "I experience consistency in who provides my care and support and in how it is provided"

According to the Care Inspectorate, almost half of care settings in Scotland are facing difficulty in recruiting the right staff. 59% of care homes for older people reported having one or more staff vacancies. Many more are suffering from high staff turnover. Inspectors regularly identify that stable and consistent staff teams are an important component of high quality social care which supports people well.

Even the private sector employers organisation, Scottish Care, has recognised the need to address workforce issues, they said:

“Social care in Scotland faces a fundamental crisis. The Care Inspectorate report together with our own work at Scottish Care states quite clearly that we are at the point of services becoming unsustainable and unable to deliver given the current recruitment and workforce crisis. The entire fabric of social care will begin to disintegrate without serious intervention and this will have a profound effect on the sustainability of wider health and social care supports."

In Scotland, a residential care worker earns at least the Scottish Living wage of £8.45 an hour. This is significant progress, but workers can earn more stacking shelves in a supermarket. Our own surveys show that younger workers in particular are choosing less demanding jobs than care, which offer more money.

We are only going to change this dynamic if we value those who work in the sector. Yes, care jobs can be satisfying and worthwhile, but that doesn't pay the bills. Care with dignity should not be at the cost of a stretched and dedicated workforce.

Scottish Care has also highlighted a nursing shortage of 28% average vacancies in nursing homes, forcing providers to pay as much as £1000 for one agency nurse to do a night-shift.

Some providers are exiting the sector. Bield Housing and Care are closing 12 care homes in Edinburgh, Falkirk, Glasgow, Borders, South Lanarkshire and West Lothian by summer 2018. Some 160 elderly people, with dependent needs  including 24 hour personal care and feeding assistance, will be evicted from the place they have called home for decades. Many are over 90 years old.

While the Care Inspectorate does some monitoring of residential care homes, their resources are limited. Councils who contract the services do very little monitoring. Earlier this year UNISON asked councils, under freedom of information, for their monitoring policies. Overall, the responses indicate that contract monitoring is limited to returns from the contractor and review meetings with them. There is very little monitoring of the actual service delivery.

Anyone who listened to the voices of care workers in parliament today will understand that the standard of care needs to improve. 

Better care comes at a price, and so we need to have a debate in Scotland about how care should be funded. That includes difficult discussions about inheritance and contribution, directly or through taxation. It is crystal clear that we cannot go on in the same old way. UNISON's Residential Care Charter can raise standards, and help recruit and retain care workers. Older people in Scotland  deserve better.

Welcome energy decisions, but we must be bolder

There is no shortage of activity on energy policy and we haven’t even heard the outcome of the Scottish Government’s energy strategy consultation.

Let’s start with fracking. The Scottish Government has announced that the existing moratorium would continue ‘indefinitely’, which is an effective ban given their planning powers. This follows a similar ban on underground coal gasification. It will be the subject of a vote in the Scottish Parliament, but that should be a formality, as only the Tories support fracking. 

Claudia Beamish MSP still has her members bill which would put in place a stronger legislative ban. The problem with using planning powers is that the moratorium could be overturned very easily, unlike legislation. I suspect the government has decided to go down the moratorium route to avoid compensation claims from INEOS, who now have drilling licences that they can’t use. However, as the minister said, fracking, “cannot and will not take place in Scotland” - and that is the practical effect.

The overwhelming majority of people in Scotland will welcome this decision. A staggering 99% of the 60,000 respondents to the consultation supported a ban. Apart from INEOS, we had a grand rant from Jim Sillars, who claimed that people didn’t know about the consultation. Well, 60,000 respondents would indicate that claim is mince, not to mention the noise campaign groups having been making on the issue. Jim also expects trade unions to put pressure on the government to rethink the ban at the STUC. I wouldn’t hold your breath on that Jim, most unions are opposed to fracking. 

And you won’t win us over with nonsense claims about how fracking will end fuel poverty. Scotland’s geology means so little fracked gas could be extracted that its use would be for industrial, not domestic heating. Even if it could be extracted in any quantity, the cost would be prohibitive. That is why the investment is drying up for drilling in England and the companies are going to the UK Government with their begging bowl.

The next big announcement by the FM was the establishment of a state owned national energy company. Details on this are a bit scarce, but the announcement points, at least initially, to a retail operation. This is not exactly an original idea, with operations like Robin Hood Energy in Nottingham, Our Power Energy run by housing associations and the People’s Energy Company based in Musselburgh. 

A national energy company is something UNISON supported in its response to the energy strategy consultation. However, we envisaged a more radical option that involves generation and transmission as well as retail. We also support a big role for municipal energy - generating electricity, managing distribution grids, running energy efficiency schemes as well as retail sales. This is very common across Europe and seriously challenges the ownership model in Scotland, something the Scottish Government has been unwilling to do. The big energy companies’ reaction to the announcement last week, indicates that some modest retail competition doesn’t worry them very much. 

The UK Government’s stop-start efforts to introduce a price cap on energy bills, has once more run into trouble. The minister claimed the cap would be in place this winter, a suggestion that was promptly contradicted by Ofgem. The legislation could take a year and then many months more for Ofgem to implement it. Shambles doesn’t even begin to describe this. 

All the usual suspects have been dragged out to tell us how wonderful the market is - all we need to do is get into switching supplier. Meanwhile, in the real-world consumers are increasingly supporting real public ownership options as set out the Labour manifesto. The TUC joined that call at its recent Congress, unanimously backing a motion that supports returning the energy sector to public ownership and democratic control. The motion also called for a mass programme of energy conservation and efficiency, a just transition strategy and investigating the long-term risks to pension funds from investment in fossil fuels.

The last few weeks have seen some important energy policy decisions that could help reshape our energy strategy. However, that will only happen if we are bolder and resist tinkering around the edges.

Improving the governance of public bodies

Scotland's public services are administered by some 200 public bodies. Most of these are run by boards that make the key decisions on the majority of public spending in our country. This means we should pay close attention to the governance of public boards.

In 2010 Audit Scotland published a report on the role of boards that made a number of recommendations. Holyrood's Public Audit Committee has recently conducted an inquiry into the same issue and have published their findings in a letter to the Cabinet Secretary.

Some of the key points they make include:

• Encouraging board members to provide an effective challenge to board chairs and chief executives, preventing ‘group think’ on our boards. As the recent SPA issue has highlighted, corporate responsibility should not be a means of silencing ‘difficult’ voices;
• The committee questions whether the involvement of a senior independent director on a board, as is the case in some parts of the private sector, could be a useful, additional check and balance on the performance of the board chair/ chief executive. Board's also need to establish a fully effective and transparent means of assessing the performance of all board members;
• It is essential that the public appointments process attracts the best possible candidates, who should not be discouraged by the complex process. The current system may reward those who are most adept at repeating public sector jargon;
• New legislation should give greater consideration to governance arrangements. Some of the problems have stemmed from poor initial decisions on governance arrangements;
• There is considerable variance in the governance arrangements across boards and not always a clear rationale for such differences; 
• Boards also take differing approaches to transparency such as holding meetings in public or private. The committee's view is that boards should be as transparent as possible and should meet in public unless there are justifiable reasons for meeting in private.

I contributed to an informal evidence session during the inquiry and the recommendations are very welcome. The membership of boards has become very 'samey', with the usual suspects dominating appointments. I have heard more than one board Chair use the phrase 'a safe pair of hands'. This isn't likely to to provide the sort of challenge the Committee is referring to. 

Workforce representation can provide a real challenge. The Fair Work Convention report recommended there should be a worker representative on every Scottish public body. Some have non-executive directors with a workforce interest. While these appointments offer an expertise that might otherwise be ignored, they are not a substitute for an employee director. However, such directors need to be supported and accountable, otherwise they can become isolated and less effective.

There is a tendency to use the shambles that is the SPA to highlight all that is wrong with public boards. The treatment of Moi Ali was both shocking and a 'good' example of the issues highlighted by the committee. However, we should remember that the structure of governance between Police Scotland and the SPA underpins many of the problems. There was a clear failure to recognise the governance problems this would cause when the legislation was going through parliament.

While the SPA is the most well known example, it isn't the only one. I can think of a number of NDPB boards that provide very weak governance. FE colleges are one as the severance packages row has illustrated. Food Standards Scotland is another, with the food industry having too great an influence. Most boards could do better on transparency.

In fairness it has to be said many of these governance failures are not unique to public boards. There has been a failure of governance in private and voluntary sector boards on pay and workforce issues. In addition, you can only appoint from applicants and many people of working age simply do not have the time to participate. On my way to giving evidence to the committee I bumped into an ex-steward who is now a senior manager in a private company that makes a big play of corporate governance. He told me that serving on public and voluntary sector boards used to be encouraged - now it is barely tolerated.

The Audit Committee recognises that some progress has been made in recent years, particularly over gender balance. Government now needs to focus on strengthening other aspects of governance. This report is a good starting point.

Funding, not more quangos will improve care integration

The implementation of health and care integration won’t be achieved on the cheap. While there should be long-term savings and better care from a shift to community services, it will take time to realise that ambition.

The Scottish Parliament’s Health and Sport Committee has been holding an inquiry into the budget for next year. We don’t have much idea how big the pot will be until the UK Autumn Budget and the Scottish Government decides on its own tax policies. However, that still allows some scope for an examination of the principles that underpin the budget.

The Integrated Joint Boards (IJB) are now responsible for some £8.3bn of expenditure – a substantial part of the Scottish budget and supplemented by local taxation. In evidence to the committee the IJB finance officers highlighted that resources are not keeping up with demands. They said:

“There is emerging evidence which indicates that the current level of resources is less than that required to meet current cost and demand pressures. In practical terms this means that the required shift in the balance of care will take longer to achieve. A number of Integration Authorities have modelled the level of additional resources required to meet cost and demand pressures, with estimates between 3% (for 2018/19) and 14% (over two years) of existing budget.”

The clear message to the committee was that increased demand, largely due to demographic change, means that they don’t even receive a standstill budget. Transformational change comes with a much bigger price tag.

Measures to reduce unplanned admissions to hospitals and cut delayed discharges can be successful. A number of IJB performance reports demonstrate progress. Not least in Glasgow, which claims continuing decreases in delayed discharges with acute bed days lost falling from 38,152 (13/14) to 15,557 (16/17). However, the picture continues to vary across the country. As I said while giving oral evidence to the committee; unplanned admissions will continue until a full social care service is in place – hospitals don’t turn patients away.

I did notice a definite pitch from IJB directors and finance leads for direct funding and greater control. We should remember that IJBs don’t employ staff and get their budgets from health boards and councils. Their complaint is that funding ‘doesn’t lose its identity’ in this system and they have matrix performance monitoring. Concerns over double counting of health and care funding are valid, as are the constraints of ring-fencing.

It was entirely predictable when you create a system that co-ordinates services that sooner or later the leaders want to create an empire that they have more control over. This leads to a demand for stand-alone bodies – in effect a whole new set of local quangos. 

This demand should be resisted. The change that is required in care cannot be achieved by IJBs in isolation. One of the points I picked up from trade union colleagues in Norway was that separating the management of acute and community services made it that much more difficult to achieve resource transfers. The same applies to councils, who run range of other services that impact on health; like housing, planning, libraries and leisure services. You don’t join up services by fragmenting them even more.

From a staff perspective, such direct control would involve a massive transfer of health and care workers to new organisations. A move that will be resisted by all the trade unions for good reason. Such a transfer would take many years and the harmonisation negotiations would be a complete nightmare. It would require a massive funding pot and divert staff and management effort for years.

It is clear that transformational change in the health and care system requires a significant increase in funding. While there are still some organisational and cultural barriers to integration, more local quangos are not the solution.