Scotland’s Care Home census shows the number of care homes reduced by 18% in the decade to the end of March this year, while the number of care home places – over 9 in 10 being for older people – fell by 5%.

The recent Highland Social Care Conference in Fort William, co-hosted by Inverness, Skye and West Ross-shire MP Angus MacDonald and his SNP Holyrood counterpart, Kate Forbes MSP, heard care home places in the West Highlands have fallen by over 25% since 2011.

The keynote speaker at the conference was Scottish Care Chief Executive, Dr Donald Macaskill. Later this week we will publish the part of his speech examining how Scotland can reimagine care. In this passage, Dr Macaskill focuses on the acute challenges in both sustainability and workforce faced by the older people’s care home sector.

“I'm intrigued today that we're meeting on the day that COSLA colleagues in local government have published a report and a message calling for an immediate £750m increase in funding for social care provision in Scotland, because, in their words, they consider there to be so many challenges and such a fiscal shortfall that an immediate increase in expenditure is necessary to sustain and maintain the current system.

The National Care Home Contract

The National Care Home Contract has been briefly mentioned, and as somebody who, for the last 10 years, has led negotiations – it's a negotiation between private, charitable, not for profit, social care providers, and local government – I have a culpability in the fact that the National Care Home Contract is failing. It has failed. It's not working, and it certainly doesn't work for rural and remote and island communities.

When it was developed, it was unique in the United Kingdom. It provided stability in a world where there was very little stability and sustainability, and it gave a guaranteed income per resident per week for each care home. The gap between what the state funded under the National Care Home Contract and what was privately funded by an individual was relatively narrow.

The gap now, in terms of a private funder and what the state funds, is hugely significant. Indeed, independent analysis due to be published soon will suggest that the differential lies between £400 and £500 and, lest myths continue, that differential assumes a return or profit – return if you are a charity, profit if you are a private business – of 6%.

If you go and get a long term ISA for £1m, you will get 5.5%. So there is very little appetite for anybody to invest in private delivery of care and support if it is only based on state funded rates. You would be, quite frankly, insane to waste your money building a private care home in any part of Scotland, unless you were guaranteed 100% of private income. [MP Angus MacDonald and researcher Lucy Swale’s] report shows quite clearly that historically, economically, demographically, that is not possible in the West Highland communities that we're talking about. There is not a significant private market here.

We need to explore whether or not we need, first of all, to have a different model for our island and rural and remote communities within a national contract. And, secondly, how do we spend the money that we're spending?

It may seem a lot of money: £1,021 per resident per week. But if you contemplate that is for 24/7 nursing care and support, and that 78% goes to staff wages – and those staff wages are still at the minimum level – there is not a lot of wriggle room within that amount of money.

When the cost of a patient in an NHS hospital without treatment ready for discharge, which in Scotland is between £2,400 and £2,980 a week, there's an economic nonsense in terms of the way in which we are currently spending, or misusing, our money.

National Insurance

Providers are really struggling.

I'm trying not to be overly political, but I'm going to have to be slightly. One of the massively negative impacts of the new Labour government was its decision to increase Employers’ National Insurance.

I can tell you with confidence that, of the care homes that have closed this year, at least half of them have closed because of an inability to maintain finances as a direct result of the cost of the UK government's increase in national insurance. And there are colleagues here from the hospice sector who have equally been deeply impacted by that blanket provision, which has not been sensitive to the reality of delivery.

Funding social care

We have to get serious around the fact that there are huge gaps in the way in which funding is being allocated.

A report which was submitted to government several months ago now, estimates that health and social care partnerships have an in-year debt across Scotland of something in the order of £550m.

At the beginning of the year, that meant that many of our care home members were operating in areas where there was a ‘two out, one in’ policy. To be blunt, that was two deaths and one admission. In one part of Scotland last week, that had moved to three to one. That's the reality of provision at the moment.

In many parts of Scotland, on average, the waiting time or a financial assessment to be undertaken, which this time last year was between six and eight weeks, is now between 16 to 18 weeks.

What is happening, to use the terms used by Age Scotland, is that people are literally dying whilst they're waiting for a social care package, either to move into a care home or to have a home care package delivered to them.

We don't see them and therefore we don't recognise the reality of loss of life because of fiscal decisions – not because there isn't availability of service, but because there is an absence of resource to enable that service to be delivered.

That is happening as we speak. But, because those individuals are not lined up in a queue outside an NHS hospital with the media there with a camera, it's not told. We don't hear that story. But believe me, I hear it every week, every day, by emails and phone calls, from people who are desperate to have mum admitted into a care home or to have dad get a home care package in the community because he can no longer live independently.

People

The second major issue relates to our workforce. There is very little point having a beautiful care home if you don't have the staff who are skilled, professional and competent and prepared to work in that care home and live in that local community.

I don't need to tell anybody in this room of the workforce crisis which is being faced right across the board.

I am on record as saying that I find it unacceptable that you can get more for walking a dog along the streets of Edinburgh than you can for sitting with somebody and holding their hand in the last moments of their life before they die.

I was in McDonald's in Fort William last weekend on my way to Skye, and I saw an advert for new entry workers in McDonald's Fort William for £13.85 an hour.

I applauded nearly a decade ago the Scottish government's decision to not just award frontline staff the minimum wage, but to increase that to living wage, which is £12.60 an hour now and next year is going to go up £13.45.

How we are going to pay for that, I don't know. But I think that people who are regulated, who are registered, who are professional, who are skilled – regardless of the rhetoric about this being a low skilled workforce – who are working in social care, deserve every penny.

I have long believed that we need to move to an equivalence in terms of terms and conditions and pay between social care and the NHS, because the divide is, quite frankly, a nonsense. And we need to start operating as, and believing that we are, one system. I know no private organisation that's not willing to make the adjustments to enable that to take place.

So we have to be realistic about the challenge of our workforce around pay. But, added to that, there was the decision, again by the UK government, to end the Social Care Visa.

Social Care Visa

I had a phone call this week with a provider who said she has 12 members of staff who are on international visas, and eight of them have had their visas rejected by the Home Office.

Another time will I tell you some of the discriminatory, racist behaviour and actions of some officials from the Home Office but, at the moment, all I would say is that what we warned in the summer about the loss of this lifeline contribution from international colleagues. It isn't going to happen in 2027 when the UK government said we would see the impact. It is happening now.

I know that there are, without naming them, many care homes in the Highlands whose proportion of international colleagues is over 50%. I am extremely concerned that, without a change to UK immigration policy, or without the ability to recognise the need for Scotland to exercise its own approach to social care and sector immigration, we will not be able to sustain our workforce even at the levels that we have at the moment.

The solutions I am going on to talk about will become aspirational, cloud cuckoo land, unless we get the fiscal and political commitment to value those who have for long been part of our communities.

Every year, I chair our awards judging experience and this year we've had more nominations for the National Care Awards than we have ever had before. I can tell you that at least 20% of these excellent, quality candidates are international workers. How dare anybody say that they are unskilled, that they are only welcomed because they provide cheap labour.

These are people who are the best of us. They have made our communities thrive and flourish – be it their children going to our local primary schools or their partner contributing to our local industries. And their loss will really rip the heart out of communities. Indeed, it is already beginning to tear those communities apart.”

 

You can read Dr Macaskill’s blog Beyond the Edge: from ‘crisis’ to reimagining social care in the Highlands on the Scottish Care pages.

Read more:Councils demand £750m boost for social care in 2026; Fixing social care funding must be council “priority”; “Critical” strain on care nursing workforce; New visa rules could wipe out entire care teams

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