Accessing adult mental health services in Scotland remains slow and complicated for many people. In particular, ethnic minority groups, people living in rural areas and those in poverty all face additional barriers.
There have been big funding increases for services since 2017, but a lack of data makes it hard for the Scottish Government to see the impact of that spending. Waiting times for psychological therapies have improved. But ministers do not measure the quality of wider mental healthcare services, or whether they are improving people’s health.
The mental healthcare system is fragmented. The Scottish Government, NHS boards, councils, Integration Joint Boards, Health and Social Care Partnerships and the third sector are all involved in funding, planning or providing services. This makes accountability complex. And it causes complications and delays in developing care focused on the needs of individuals.
The Scottish Government plans to increase its Mental Health Directorate budget by 25 per cent and ensure that ten per cent of the front-line NHS budget is spent on mental health by 2026.
They have also committed to giving all GP practices access to community based mental health and wellbeing services. These commitments are essential to improving access to services and relieving pressure on the mental health workforce. But ministers’ plans are not on track.
Stephen Boyle, Auditor General for Scotland, said: “The Scottish Government needs much more information to understand the difference its investment in mental health services is making, from specialist services to community-based support.
“That planning must include moving beyond using waiting times as the sole measure of whether services are improving the lives of those in need. And it needs to include a costed delivery plan for the care that people can expect in their communities.”
Ronnie Hinds, Interim Chair of the Accounts Commission, said: “Councils and Integration Joint Boards have a vital role to play in improving the availability and quality of data needed to plan services and get the right levels of staffing in place.
“They also need urgently to develop shared goals and targets to improve how housing, welfare and other services work together in order to address and prevent the root causes of poor mental health.”
Scotland’s Integration Joint Boards (IJBs) face considerable financial challenges and immense pressures on their workforce, says public spending watchdog Audit Scotland.
IJBs have reached the point where significant transformation will be needed to ensure the long-term capacity, financial sustainability and quality of services individuals receive.
IJBs plan and commission many community-based health and care services. Demand for these services is increasing, in part due to demographic change and support for people with increasingly complex care needs.
The number of care hours for those aged over 65 reached nearly 25 million in 2021/22. The proportion of care services reporting vacancies increased by 11 per cent to 47 per cent, with a 30 per cent turnover of staff each year.
Most IJBs underspent on providing services in 2021/22. This was largely because of difficulties in recruiting staff, which led to unplanned vacancies, and pandemic-related reductions in service provision. The reductions in service provision were likely to have contributed to an increase in unmet health and social care needs.
In 2021/22 IJBs returned significant surpluses, with reserves doubling to over £1.3 billion. This was mainly due to additional funding received late in the year for specific policy commitments, including Covid-19. The Scottish Government are currently exploring options to recover around two-thirds of the unspent Covid-19 money held in reserves.
Across Scotland, IJBs have a combined projected funding gap of £124 million for 2022/23.
To be financially sustainable in the longer-term, IJBs must reduce their reliance on reserves. All IJBs must put in place detailed plans that clearly show how they will achieve the needed ongoing savings on a recurring basis and support urgently needed service transformation.
William Moyes, Chair of the Accounts Commission said: “Change is needed now – it cannot wait for a National Care Service. Action is needed to tackle funding pressures, which are under increasing stress from rising demand and cost pressures.
“The workforce challenges are considerable, with mounting unmet need.
“We need to see services focus on prevention, with appropriate funding in place to transform the way services are delivered and to improve lives. “
Local government organisation COSLA agrees.
COSLA Health & Social Care Spokesperson, Councillor Paul Kelly, said: “Today’s report from Audit Scotland is concerning and highlights the enormous pressure our health and social care infrastructure is under.
“People across Scotland rely on vital health & social care services every day, and it is critical that there is meaningful investment in the system which ensures their long-term capacity.
“We must ensure focus remains on front-line service improvement and sustainability, rather than the bureaucratic structural change presented through the National Care Service Bill.”
Many people are waiting longer for housing benefit claims to be processed as services across Scotland’s councils face rising workloads, fewer staff and high sickness absence levels.
The Accounts Commission, the independent body that holds councils to account, says councils need to better manage staffing levels and workloads, and put in place contingency arrangements.
Council benefit teams are operating with greatly reduced staffing levels, often with a deficit of ten per cent or more, and sickness absences are persistently higher than the national average. Flexible location working arrangements are now prevalent in council benefit services.
Whilst there has been a drop in the amount of short-term sick leave, it is also taking longer to process benefit claims. As people claiming housing benefit are often in urgent need of financial support, councils must better understand the impact of flexible location working arrangements on the delivery of the service.
Councils are implementing some improvements to service delivery and people’s experience, through new technologies such as robotics and automation. This will help improve access to benefit services, increase response times and reduce the number of days taken to process claims.
William Moyes, Chair of the Accounts Commission, said: “Clients needing housing benefit are often in urgent need. It is vital that councils have sufficient resources, alongside experienced staff, to manage increased workloads and staff absences. This will help ensure services are delivered more efficiently and effectively.
“It is positive that councils have continued to invest in different technologies, helping achieve some improvements. But the level of staff absence is a significant concern, and it is vital that councils understand the potential impacts of flexible location working arrangements on the performance of the service they provide.”
Councils across Scotland faced significant financial challenges during 2021/22 and are now entering the most difficult budget setting context seen for many years. Increasingly difficult choices about spending priorities will need to be made.
The Accounts Commission, the independent body that holds councils to account, said that even with additional Covid-19 funding during 2021-22, councils had to make significant savings last year to balance their budgets.
Many councils have also used reserves to bridge funding gaps and fund vital services. This is expected to be the case in 2022/23. The £570 million of additional funding for 2023/24, announced in the December budget, will help councils address upcoming cost challenges, but further change and reform across all councils is required to ensure longer-term financial sustainability.
When compared to the 2013/14 Scottish Government revenue funding position to local government, 2021-22 represented the first real-terms increase in six years (excluding one-off Covid-19 money). But an increasing amount of council funding is either formally ringfenced or provided on the expectation it will be spent on specific services and national policy objectives. This supports the delivery of key Scottish Government policies yet removes local discretion and flexibility over how these funds can be used by councils.
William Moyes, Chair of the Accounts Commission, said: “It’s clear the financial situation of councils is increasingly fragile. Councils are having to deal with the effects of inflation, the increasingly desperate cost of living impacts and rising demand for services, whilst at the same time delivering vital day to day services to their communities.
“To be financially sustainable, councils must deliver savings and reduce reliance on non-recurring reserves to fill budget gaps.
“If they are to find a safe path through the difficult times ahead, councils need to focus more on service reform, alongside meaningful engagement with their communities, about what services can be provided given the financial pressures they are facing.”
Around a third of children and young people in Scotland’s publicly-funded schools (that’s around 233,000 pupils) need additional support. And that number has been increasing for years (writes STEPHEN MOORE, a Member of the Accounts Commission) .
There are many reasons why a child might need additional support. These can be as varied as having a life-threatening physical condition to being a young carer. Most children and young people who need additional support go to a mainstream school, with a much smaller number going to special schools.
The Scottish Government’s stated ambition is for all children and young people in Scotland to have the opportunity to grow up loved, safe and respected, enabling them to reach their full potential.
Every child has the same rights under the United Nations Convention on the Rights of the Child, including the right to an education that develops their personality, talents and abilities to the full, and the right for their parents to get the support they need. Schools, councils and other public bodies are required to work together to provide the right type of support for all children and their families. But this isn’t always happening as it should.
The needs of children and young people vary considerably. Some children only have a short-term identified need. Others have complex needs that will require ongoing support throughout their lives. Some children and young people need help involving specialist educational support as well as social work services, health services and the voluntary sector.
At their best, these multidisciplinary teams work together, enabling children and young people to get the support they need, empowering them to reach their full potential and live the life they choose.
These ambitions aren’t, however, consistently being delivered in practice. In 2020, an independent review found that not all pupils in Scotland are always getting the additional support they need, when they need it. In many cases, individuals’ needs are not given the focus they should be. Numerous aspects of additional support therefore need to be improved.
It’s distressing and frustrating that we repeatedly hear of the barriers that some families fight against to get the right support to help their child to learn. Too often, families are worn down by a prolonged search for the right support, and by having to manage a crisis that could have and should have been avoided. Families are partners with public services and should be regarded as such.
On top of that, transitions between school stages – and how they are managed – can have a big influence on the success or otherwise of someone’s journey through the education system.
A child’s needs can evolve over time, from pre-school until after they have left school. Not getting the right support both at these different stages and to make moving between the stages as seamless as possible can have a lasting impact on learning, wellbeing and happiness. Public services are required to anticipate these changing needs and plan accordingly.
Councils provide support in different ways, with a wide variation in spending on pupils who need additional support. This partly reflects the different ways services are provided and the varying costs of supporting individuals – but may also reflect local decisions by councils to prioritise between a wide range of services.
Education aims to improve the health and wellbeing of children and young people, supporting wider outcomes such as life skills, apprenticeships and employment. This is set out in the National Improvement Framework and is embedded across the education system. School education and success shouldn’t just focus on exam results. It’s vital to monitor the outcomes that matter most to individuals who need additional support but, as we’ve said previously, information to allow this to happen isn’t always available.
From the information that is available, even the current measures show wide disparity. We know that children and young people who need additional support don’t always get the opportunities they deserve. Overall, a smaller proportion of school leavers with additional support needs progress to a ‘positive destination’ such as college, university, training or employment. This potentially affects their life chances and personal fulfilment.
And the proportion of children who achieve expected Curriculum for Excellence Levels for their stage at school is significantly lower for pupils who need additional support compared to those who don’t.
Across so many areas, Covid-19 has exacerbated and deepened risks and inequalities. School closures and reductions in vital support services have intensified inequalities for children and young people who need additional support. We know that individuals who have disabilities and complex needs, along with their families, were particularly affected.
The impact on the mental health of children and young people who need additional support has also been significant. Some families have asked if their child can repeat a year at school due to the difficulties they’ve experienced, or because there was insufficient planning to move from one stage of learning to another.
However, it must be recognised that for some children who need additional support, learning at home rather than in a school environment was a more positive experience.
The Scottish Government and councils are already working to implement changes following the independent review in 2020. These changes need to consider the wide range of services that should work together to put the child/young person and their family at the centre. Public services need to improve how they’re joining up, across professions, to plan and provide the right support to meet individuals’ needs.
We’ve seen that many public services responded quickly to the challenges presented by the pandemic, showing that change can happen quickly and effectively to support individuals and communities. And councils have the power to improve services as they ‘build back better’. Children and young people must be given the support and access to the right services that enable them to flourish and thrive. It will be crucial to make improvements to services and staffing that ensure continuity as someone moves through the education system.
Central to the Accounts Commission’s priorities is emphasising and reporting on the debilitating and life-impacting inequalities faced by too many across Scotland’s communities. The lack of the right support, at the right time, for children and young people who need additional support – and their families – can exacerbate and intensify these inequalities. So we will continue to focus on this important area as part of our ongoing work.
A spokesperson for the Scottish Children’s Services Coalition commented: “The blog raises issues that we have been highlighting for several years, reiterating our concerns that children and young people with additional support needs (ASN) and their families, are on many occasions not receiving the care and support that they need when they it.
“There are still too far many barriers faced by families seeking support, often leaving them in a crisis situation that could easily have been avoided with prompt access to the appropriate services.
“While we have witnessed a more than doubling in the number of those with ASN, such as autism, dyslexia and mental health problems over the last decade, putting an immense strain on services, there has been a cut in spending on additional support for learning and a slashing in specialist educational support.
“Covid-19 has had a further major impact on those with ASN, for whom exclusion from school and lack of vital support proved devastating. This however exacerbated a situation that existed long before that and we are potentially facing a ‘lost generation’ of vulnerable children and young people, not able to access the support that they need, with a resultant impact on the economy and society.
“We would urge the Scottish Government and newly elected local authorities to work together to ensure that those children and young people with ASN are a priority and that they can access the necessary support to allow them to reach their full potential.”
A detailed analysis of how Covid-19 business support funding was distributed during the pandemic is not possible due to gaps in data, according to spending watchdog Audit Scotland.
The Scottish Government provided about £4.4 billion of grants and non-domestic rate reliefs between March 2020 and October 2021, mostly paid out to businesses by councils. The government announced a further £375 million of support in December 2021 following the emergence of the Omicron variant.
Steps were taken to improve the management of funding during the pandemic.
But there was not enough focus on gathering detailed data on how money was distributed and how quickly applicants received funding.
This means:
The Scottish Government does not have an analysis of the total amounts paid out from the more general schemes to different economic sectors
For sector specific funding administered by national organisations such as Scottish Enterprise, around 20 per cent of payments cannot currently be matched to council areas
Similarly, information to enable wider analysis of how funding supported specific groups, such as the female owned businesses disproportionately hit by Covid-19, is not available from Scottish Government centrally held data.
In late 2021, the Scottish Government completed retrospective impact assessments to consider how business support funding addressed inequalities. A retrospective fraud review of funding that councils administered was also carried out.
The government is currently undertaking a large data cleansing exercise to ensure that the datasets for individual funds, including those administered by councils, are complete.
Covid-19 business support schemes were administered at pace in exceptional circumstances.
But knowing where the money went matters, to get future policy development and delivery right.
Stephen Boyle, Auditor General for Scotland, said: “These business support schemes were administered at pace in exceptional circumstances. But knowing where the money went matters.
“To get future policy development and delivery right, it will be important for the Scottish Government to fully understand how funding was used to support specific businesses and groups over the last two years of the pandemic.”
William Moyes, Chair of the Accounts Commission, said: “Councils’ fraud arrangements are generally robust, but they were heavily relied upon to ensure businesses were eligible for funding during the pandemic.
“Councils will need to continue to work closely with the Scottish Government to ensure a better picture emerges of how money was distributed.”
Responding to the Audit Scotland report, Economy Secretary Kate Forbes said: “I am pleased that both Audit Scotland and the Accounts Commission have recognised how quickly the Scottish Government was able to establish a wide ranging business support package in order to help safeguard thousands of businesses and jobs.
“This includes providing direct support to over 4,000 businesses and over 5,000 self-employed people who were facing hardship but ineligible for UK Government funding support.
“I am equally pleased this report reflects the unique and challenging context in which new support packages had to be established, and that despite the speed and scale of our response, we were able to work closely with industry, our enterprise agencies and local authorities.
“This helped to ensure the delivery of the business support funding was a shared endeavour and minimised risk and fraud. Without the efforts of our partners, we wouldn’t have been able to deliver this lifeline support at the scale and pace necessary and I thank them for working so closely with us.
“Every decision the Scottish Government has taken has centred around ensuring businesses got the support they needed when they needed it – resulting in over £4.5 billion being allocated to businesses across the country, including around £1.6 billion in rates relief – which is more generous than the other UK administrations so far.
“We will now carefully consider the findings of this report and of course any lessons will be learned, but fundamentally this report shows the decisions we took ensured lifeline support reached key businesses promptly and our economy continued to grow by 7.1% despite the necessary public health restrictions.”
Drug and alcohol services in Scotland are complex and a clear plan is needed to improve people’s lives and increase transparency around spending, says public spending watchdog Audit Scotland.
Drug-related deaths have been rising steeply since 2013. A record 1,339 people lost their lives to drugs in 2020 – the highest rate in Europe. Alcohol deaths have been decreasing since the early 2000s, but rose by 16 per cent in 2020, when there were 1,190 deaths.
Alcohol and drug partnerships (ADPs) are charged with helping people at the local level. But how services are delivered remains complicated and lines of accountability are not always clear.
Overall funding for ADPs fell over the last few years before returning to 2015 levels by April 2021, but with no real terms increase. The Scottish Government has also provided additional investment for new initiatives, including a drug deaths taskforce and new evidence-based treatments and standards. But it is too early to gauge their effectiveness.
Spending remains difficult to track, including how money is distributed and what it is achieving. For example, in September 2021 the Scottish Government committed to invest £250m to reduce drug deaths – £50m for the next five years.
But details of how much of the £50m will be spent on each local area, or how the funding will be distributed, have not been published. More widely, data gaps around drug and alcohol referrals, waiting times and outcomes persist. And there is a considerable time lag in public reporting.
Stephen Boyle, Auditor General for Scotland, said: “We’ve recently seen more drive and leadership around drug and alcohol misuse from the Scottish Government. But it’s still hard to see what impact policy is having on people living in the most deprived areas, where long-standing inequalities remain.
“Drug and alcohol data is not good enough, and there is a lack of transparency about how money is being spent and allocated. The Scottish Government needs to set out an integrated plan, with clear measures showing how extra spending is being used to reduce the tragic loss of life we’ve seen over the last decade.”
William Moyes, Chair of the Accounts Commission, said: “Delivery of drug and alcohol services in Scotland is complex and difficult to navigate, with many organisations working across different sectors. What we need to see now is clearer accountability across all partners.
“In the longer term, more focus is needed on the root causes of drug and alcohol dependency and breaking the cycle of harm stretching down generations and across communities.”
Action is needed now to change how Scotland’s social care services are delivered so that it meets the needs, and improves the experience of, people relying on care and support, say Scotland’s spending watchdogs.
The joint briefing by the Accounts Commission and the Auditor General for Scotland says fundamental issues and threats to the future sustainability of Scotland’s social care system need to be addressed. The pandemic has exacerbated long-standing challenges, highlighting the precarious situation of many vulnerable people who rely on social care or support.
Over £5 billion a year is spent on delivering social care services, yet some services are at near crisis point. There needs to be a shift in how this money is used, with a far greater emphasis needed on preventative care that meets the needs of individual people. Service users do not always have a choice or say about what support works best for them. Nor are carers getting all the support and advice they need, despite existing legislation.
Now the Scottish Government, together with its partners, must listen and bring together the views and experiences of service users and carers. This will support the delivery of their long-held ambitions for social care.
The 200,000-strong workforce is under immense pressure and feels undervalued. There is a high vacancy rate and a continuing problem of recruiting and retaining this workforce into roles which often have low pay and poor conditions of employment. At the same time demand for social care services continues to increase.
Commissioning social care services tends to focus on cost, rather than quality or outcomes. Worrying limitations in social care data has created major gaps in the information needed to inform improvements.
William Moyes, Chair of the Accounts Commission, said: “There are significant problems with the delivery of social care services. These services are vital, yet we have a workforce that’s not adequately valued or regarded.
“Staffing shortages are a major issue across the sector and not all people’s needs are being met. Too often a focus on costs comes at the expense of delivering high quality services that aren’t at the heart of the needs of individuals. The additional funding to achieve this will be significant. Not taking action now presents a serious risk to the delivery of care services for the people who depend on them.
Stephen Boyle, Auditor General for Scotland, said: “We cannot wait another five years until the planned National Care Service is in place. Action must happen now, and at speed, by the Scottish Government.
“There must be clear timescales for delivery, demonstrating that lessons have been learnt from previous reforms of health and social care services. This will create a strong foundation for the government’s vision to create a National Care Service.”
COSLA’s Health and Social Care Spokesperson, Councillor Stuart Currie, responded to the Audit Scotland report on social care: ‘The Audit Scotland report sets out many of the challenges that Local Government has consistently highlighted for many years now.
“There is an urgent need to address these challenges – many of which have been exacerbated by the pandemic – by working with our partners across Scottish Government, in the third and independent sector, and most importantly, people with lived experience.
“We agree with Audit Scotland that Social Care reform cannot wait for a National Care Service to be implemented. Local authorities are central to delivering the right care at the right time in the right place.
“Local Government recognises that we cannot stand still if we want to create meaningful change for our communities. We continue to work with Scottish Government to progress our shared commitments outlined in our Joint Statement of Intent so that we can now begin to implement much of the reform that was called for in the Independent Review of Adult Social Care.
“Fundamental to these shared commitments is a recognition that through empowering people, valuing our workforce and embedding a human rights-based approach in social care, we can begin to deliver real solutions for our local communities, unpaid carers, and our workforce.”
Accounts Commission:Councils and communities worked well together but impacts of Covid are unequal
Scotland’s councils reacted quickly, working alongside communities and partners to address the unprecedented challenges created by Covid-19, says a new report from the Accounts Commission. Many challenges remain significant, however, made more urgent by the multiple impacts of Covid-19 on communities and services.
Councils have a critical role in providing vital services which communities depend on. In its Local Government Overview 2021 report, the Accounts Commission, who report to the public on the performance of local government, make clear that councils, alongside their partners, quickly provided innovative and sustained support to vulnerable people.
This included supporting those who were shielding or self-isolating, switching to delivering services digitally and managing significant funding to support local businesses.
With many council services disrupted, stopped or reduced, in particular education, social care and culture and leisure, the impact on some service users was severe and unequal. This included carers who lacked access to respite care, people with learning disabilities who were unable to access critical services and support, those receiving care at home and school children whose education was disrupted.
Covid-19 has also exacerbated and laid bare fundamental issues that need to be addressed to ensure services are maintained and that councils can tackle the multiple challenges ahead.
To help achieve this, longer-term financial certainty for councils will be vital. Whilst the Scottish Government has provided significant financial support to councils to assist in managing the net cost of Covid-19 in 2020/21, considerable amounts of funding took the form of one-off payments.
Furthermore, funding for councils beyond 2021/22 remains uncertain. Addressing this issue is vital.
Elma Murray, Interim Chair of the Accounts Commission, says: “Councils, communities and their partners have worked incredibly hard to continue to deliver vital services to local people. The stark reality is that some council services won’t restart, and some services will have to be delivered differently.
“Underpinning this is the increasingly urgent need to address inequalities throughout Scotland’s communities. And for councils this is made more challenging because they continue to operate in a climate of significant financial uncertainty, which must now be addressed.”
Progress on closing the poverty-related attainment gap between the most and least deprived school pupils has been limited. And more evidence is needed to understand educational achievement beyond exams.
A joint report by the Auditor General for Scotland and the Accounts Commission found that exam performance and other attainment measures at the national level have improved.
However, progress since 2013-14 has been inconsistent. And there are large variations in local authority performance, with some councils’ performance getting worse on some measures.
The poverty-related attainment gap remains wide and existing inequalities have been exacerbated by the Covid-19 pandemic. The national curriculum recognises that school is about more than exams.
And there has been an increase in the types of pathways, awards and qualifications available to young people. But better data is needed to understand if other important broad outcomes, like wellbeing and self-confidence, are improving.
The Scottish Government, councils, schools and the other bodies responsible for planning and delivering education were working well together before Covid-19.
That allowed them to respond rapidly in exceptionally difficult circumstances. Funding for education has remained largely static – rising from £4.1 billion in 2013/14 to £4.3 billion in 2018/19.
However, most of that real-terms increase was due to the Attainment Scotland Fund, which the Scottish Government set up to close the attainment gap.
Stephen Boyle, Auditor General for Scotland, said: “Significantly reducing the attainment gap is complex. But the pace of improvement has to increase as part of the Scottish Government’s Covid-19 recovery planning.
“That process needs to particularly focus on the pandemic’s impact on the most disadvantaged children and young people.”
Elma Murray, Interim Chair of the Accounts Commission, said: “There is variation in educational performance across Scotland, but this is not solely about exam performance.
“Education also supports and improves the health and wellbeing of children and young people, which has been impacted by the Covid-19 pandemic.
“It is vital that councils, schools and their partners work to reduce the wide variation in outcomes as well as understanding and tackling the short and longer-term impact of Covid-19 on learning and wellbeing.”
EIS General Secretary Larry Flanagan said: “The impact of poverty on children’s life chances remains a matter of huge concern, and much more needs to be done to support young people living in poverty to overcome the barriers that they continue to face.
“Schools do all that they can with insufficient resources to support young people from all backgrounds but cannot, in isolation, overcome such serious societal issues as inequality and poverty.”
“We have long known of the devastating impact that poverty can have on young people, and this has been made worse during the pandemic when young people from less affluent backgrounds have been far more likely to have had their in-school learning disrupted and to face barriers in accessing education outwith the school environment.”
“It is clear that much greater and sustained investment is needed to tackle the impact of poverty on young people’s education, and all of Scotland’s political parties must fully commit to tackling this issue in the context of education recovery during the next Parliament.”
