8. Health and Social Care
“ The delivery of health and social care services is at the core of protecting human rights”
NHS Health Scotland
8.1 Health and social care 
UPR recommendations 
- Strengthen measures to foster access of vulnerable populations, including migrants, to public services and social and health services
The Healthcare Quality Strategy for NHS Scotland contains three quality ambitions of safe, effective and person-centred care. The Patient Rights (Scotland) Act 2011 gives all patients certain rights concerning the healthcare they receive, including a right to raise concerns or complaints, and requires the Scottish Ministers to publish a Charter of Patient Rights and Responsibilities.  The Scottish Government is currently reviewing the Charter to ensure that it continues to accurately summarise the rights and responsibilities of people using healthcare services and that it is effective in raising people’s awareness of their rights and responsibilities.
The Scottish Government’s 2020 Vision is that everyone is able to live longer, healthier lives at home, or in a homely setting, and that by 2020 Scotland will have a healthcare system where, amongst other things, health and social care are integrated; there is a focus on prevention, anticipation and supported self-management; and, whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.
Health and social care integration
The integration of health and social care is one of the most significant reforms since the establishment of the NHS. It is about ensuring that those who use services get the right care and support whatever their needs, at any point in their care journey. Bringing together NHS and social care services will ensure people get the right care and support for their individual needs, and that staff across health and social care are equipped to work together to make full use of their shared skills and resources.
The budget for 2017-18 includes an additional £107 million for NHS investment in social care and ensures that budgets for Integration Authorities next year will be higher than their budgets in 2016-17. This is in addition to the £250 million transfer in the 2016-17 budget, which will be part of the core budget for 2017-18 and beyond.
In June 2017 the Scottish Government launched the new Health and Social Care Standards,  which will come into effect on 1 April 2018. These Standards will, for the first time, be applicable to all health and social care services. Designed with a human rights-based approach, the Standards focus on supporting improvement and delivering better personal outcomes for those using health and/or care services. They seek to ensure that individuals are treated with respect and dignity, and that the human rights we are all entitled to are upheld.
Anyone who is living in Scotland legally and for a specific purpose is able to register with a GP practice to receive NHS general medical services. This includes asylum seekers, refugees, migrant workers, Gypsy/Travellers, students and those joining their families. Asylum seekers who have made an application to the Home Office to remain in the UK are entitled to the full-range of NHS care and services while in Scotland, regardless of the status of their application.
The Scottish Government has established a short life working group to:
- recommend on the suitability of adapting the NHS England Patient Registration Guidance for use in Scotland
- agree a consistent approach for patient registration for asylum seekers and refugees, overseas visitors, students, people on work visas and those who are homeless
- agree a consistent approach for temporary residents
- agree a consistent approach for care on a private basis
A national standard has been introduced to ensure 48-hour access, or advance booking, to an appropriate member of the GP practice team during core hours, through either a face-to-face or a telephone consultation. Most NHS services, including those provided by GP practices, local pharmacies, hospitals or clinics and emergency services, are provided free of charge. There is also a right to free NHS eye examinations and free NHS dental examinations.
Health Boards are expected to design and put in place service models that best reflect local circumstances, and are responsible for ensuring that primary medical services in Scotland recognise cultural diversity and respond to the healthcare needs of all ethnic groups and communities.
Adult social care
The Scottish Government is undertaking a programme of reform of adult social care, focusing on new models of care and delivering change in the care at home sector, the reform of the National Care Home Contract, the workforce and self-directed support. The programme will be on supporting people who need social care support, to identify and work towards personal outcomes within a sustainable system in the broader context of integrated health and social care provision.
The National Self-Directed Support Strategy 2010-2020  is a joint Scottish Government and COSLA plan, dedicated to driving forward the personalisation of social care in Scotland. Self-directed support is founded upon the human rights principles of dignity, empowerment and collaboration, and stipulates that a human rights based approach needs to be at the forefront of assessments for social care provision and the resulting support.
In April 2014 the Scottish Government enacted the Social Care (Self-directed Support) (Scotland) Act 2013,  enshrining in law that adults, children and carers who require social care support must be given as much choice and control as they would like over how their support is delivered. This ensures that the rights of individuals are upheld and that they are empowered to be equal partners in decisions about their care and support. The Scottish Government has invested nearly £70 million of transition funding between 2011 and 2018 to embed this new approach. The Self-directed Support Implementation Plan 2016-18,  developed with a wide range of stakeholders, sets out strategic outcomes and details actions designed to address identified challenges to implementation.
The Scottish Care Experience Survey Programme is a suite of national surveys which aim to provide local and national information on the quality of health and care services from the perspective of those using them. Information on protected characteristics is routinely collected through national surveys conducted by the Scottish Government, and administrative systems used in the delivery of health care also capture a range of equality information. Both the Scottish Government and NHS Health Scotland publish evidence summaries for each equality characteristic.
The Scottish Government is currently updating the evaluation and monitoring framework around self-directed support and consulting on the data it collects around social care more broadly. The annual Health and Care Experience Survey  includes questions about experiences of care and support, focusing on feeling safe, quality of life, being treated with respect and having a choice in care and support provision. Discussions are underway on whether this limited data set can be linked to the Social Care Survey to draw robust conclusions. The data already include some user group differentiation and consultation will consider whether this can be improved.
In 2016-17 the Scottish Government conducted a feasibility study into extending free personal care to those under the age of 65 who are assessed as needing it. The 2017-18 PfG states that free personal care for those under the age of 65, who are assessed as needing it, irrespective of their condition, will receive this service. The Cabinet Secretary for Health and Sport announced that this would be in place nationally by April 2019. Implementation will require a significant amount of work, including assessment processes to separate personal and non-personal care, and putting the necessary legislative and guidance changes in place. The Scottish Government will work with local government and others to build up care capacity of properly qualified staff so that no-one who is currently receiving care sees that diminished. This is a change that will benefit at least another 9,000 people.
Healthcare staff have a duty to ensure that information and services are accessible to all, for instance through arranging interpretation or advocacy services for those who need them.
The Scottish Government’s national strategy on sensory impairment, See Hear  (April 2014), jointly endorsed by COSLA, sets out a commitment that adults and children should expect a seamless provision of assessment, care and support, and the same access to opportunities and public services, including health and social care, employment, education and leisure, as everyone else. The Patient Charter includes the right to be given information in a format or language the patient can understand. Under the Equality Act 2010, NHS Scotland is required to provide translation and interpreting services and written material wherever possible and reasonable. All NHS boards have a published accessibility policy and arrangements in place to support such needs.
People who are deaf or who are hard of hearing can access Scotland’s national health and information service, NHS inform,  using the “contactSCOTLAND BSL” service,  or by textphone and through web-chat, which is available on the NHS Inform website. NHS Health Scotland is working with NHS Boards across Scotland to support improvements, including sharing and building on best practice in the provision of British Sign Language ( BSL) interpreting services in health settings, and has developed an agreed plan of work with boards that was endorsed by NHS Chief Executives in March 2017. These, and other actions the Scottish Government is taking to improve access to health services for people whose first or preferred language is BSL, were included in Scotland’s first BSL National Plan,  published in October 2017 as required by the British Sign Language (Scotland) Act 2015.
The Scottish Government is committed to building on the work already delivered on augmentative and alternative communication ( AAC) in Scotland through A Right to Speak (2012)  and Now Hear Me (2015).  In 2016 the Scottish Parliament passed legislation to give children and adults (across all care groups), who have lost their voice, or who are at risk of losing their voice or who have difficulty speaking, a statutory right to the provision of communication equipment and support in using that equipment (Part 4 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016).
8.2 Health inequalities
The Scottish Government recognises the need for a shift in emphasis from dealing with the consequences of health inequalities to tackling the underlying causes - ending poverty, promoting fair wages, supporting families and improving physical and social environments. Scottish Government measures such as investment in affordable housing, free school meals and continuing commitments to free prescriptions, concessionary travel and free personal care, are the right approach, coupled with decisive action to address alcohol consumption, reduce smoking rates, encourage active living and healthy eating, and investment to improve mental health services.
Since 2014-15, NHS Health Scotland has used an internal prioritisation tool that includes consideration of human rights when planning work to help it focus resources on the things that will make the biggest difference in reducing health inequalities. This is being refined through an internal improvement project to align with a human rights based approach. NHS Health Scotland has also recently published its own NHSHS Equality Outcomes report. 
The Community Links Worker ( CLW) programme, funded by the Scottish Government, involves a dedicated individual working in GP surgeries, helping patients on a one-to-one basis with non-medical problems that are making them feel unwell. The programme is being delivered in areas of socio-economic deprivation (including widespread and pocket deprivation, in both urban and rural/remote areas). It is focused on mitigating health inequalities and alleviating pressures in GP practice teams. Fifty three CLWs are now in post. The Scottish Government will work with Integration Authorities to increase this number in disadvantaged areas to 250 by the end of the parliamentary session.
The Scottish Government is expanding access to Family Nurse Partnership ( FNP), an intensive, preventive, one-to-one home visiting programme for young, first time mothers and their children from early pregnancy until the child reaches the age of two. FNP aims to break the cycle of disadvantage by working directly with young mothers and their children to improve their health and wellbeing. It is currently available to first time mothers aged up to 19 in ten NHS health board areas and supports almost two-thirds of the first time, young mother population at any one time. There are high levels of engagement and retention. The expansion would see the programme offered to eligible first time mothers up to age 24.
8.3 Mental health 
Mental health strategy
The Scottish Government’s vision for mental health is of a Scotland where people can get the right help at the right time, expect recovery, and fully enjoy their rights, free from discrimination and stigma. The Scottish Government has a Ministerial post dedicated to mental health and over five years is investing an additional £150 million.
A new strategy for mental health, published in March,  sets out a vision for the next ten years and how to transform services, with a focus on themes including prevention and early intervention; responses in primary care settings; improving the physical health of those with mental health problems; and improving access to mental health services. The strategy contains an initial 40 actions. Progress will be reported on through a bi-annual stakeholder forum and through an annual report that the Minister for Mental Health will present to Parliament, starting in Summer 2018.
Parity between mental and physical health
Over the ten years of the Strategy, the Scottish Government will work on achieving parity between mental and physical health in the following areas:
- equal access to the most effective and safest care and treatment
- equal efforts to improve the quality of care
- allocation of time, effort and resources on a basis commensurate with need
- equal status within healthcare education and practice
- equally high aspirations for service users
- equal status in the measurement of health outcomes
The Scottish Government’s guiding ambition for mental health is simple but, if realised, will change and save lives - to prevent and treat mental health problems with the same commitment, passion and drive as physical health problems. That means working to improve prevention and early intervention; access to treatment, and joined up accessible services; the physical wellbeing of people with mental health problems; and rights, information use, and planning.
Human rights approach
A human rights based approach is intrinsic to actions to improve mental health and intrinsic to actions in the Mental Health Strategy. This is being done using the PANEL principles (participation, accountability, non-discrimination and equality, empowerment, and legality). The Strategy also recognises that “inequality related to disabilities, age, sex, gender, sexual orientation, ethnicity and background can all affect mental wellbeing and incidence of mental illness.” The Scottish Government’s aim is that mental health services and professionals are welcoming to all, and respond to the mental health needs of individuals in a person-centred, safe, effective and respectful way.
Scotland’s mental health and incapacity law sets out principles which have been at the forefront of a rights-based approach to law in this area. International law continues to develop and other jurisdictions have taken the step to overhaul their mental health and incapacity legislation. The approach taken in Scotland is to take account of UN treaty monitoring body observations, build on existing good practice, and learn from other jurisdictions about what works well.
Access to mental health services
As part of the additional £150 million funding, the First Minister announced a £54.1 million package of support to improve access to mental health services for adults and children in January 2016. This investment includes £24.7 million to improve capacity in health boards to see more people more quickly; £4.8 million through Healthcare Improvement Scotland to help redesign local services to be more efficient, effective and sustainable; and £24.6 million to improve workforce supply and train existing staff to deliver mental health services. This funding acknowledges the continued and substantial increase in demand for psychological therapies and CAMHS. As the capacity and provision of services have increased there has been a sustained increase in the numbers accessing treatment each quarter, and this should be welcomed.
The challenge presented by isolation is keenly felt by many in Scotland’s rural communities. The National Rural Mental Health Forum has been established to help people in rural areas maintain good mental health and wellbeing. This forum will help develop connections between communities across rural Scotland so that isolated people can receive support when and where they need it.
Child and Adolescent Mental Health Services ( CAMHS)
The Mental Health Strategy is all-inclusive and applies to all individuals and groups. The Scottish Government remains committed to meeting its target of 90% of those referred for specialist CAMHS starting treatment within 18 weeks, and is continuing to work with NHS boards to help them to make the necessary improvements.
Work on access to CAMHS and on reducing waiting times should ensure that CAMHS is available, accessible, acceptable, of a good quality, and pays particular attention to vulnerable children - such as those living in poverty, children in care, children in contact with the criminal justice system and children with a learning disability and/or autism. Improvement work on access should also consider variations in levels of demand that cannot be explained by factors such as different socioeconomic circumstances.
Relevant actions in the Mental Health Strategy include:
- Action 5 – ensure the care pathway includes mental and emotional health and wellbeing, for young people on the edges of, and in, secure care
- Action 6 – determine and implement the additional support needed for practitioners assessing and managing complex needs among children who present a risk to themselves or others
- Action 7 – support an increase in support for the mental health needs of young offenders, including on issues such as trauma and bereavement
- Action 8 – work with partners to develop systems and multi-agency pathways that work in a co-ordinated way to support children’s mental health and wellbeing
A child or young person’s wellbeing is influenced by everything around them, and by the different experiences and needs they have. The vision and practice of the Getting it right for every child approach empowers those working with children and families to operate across professional boundaries to provide support and to identify and address need at the earliest opportunity to prevent problems escalating. The eight wellbeing indicators can be used to identify what help and support a child or young person may need in order to improve their wellbeing and their mental health.
For a child, good relationships, starting with early attachment, create the setting for good mental health and resilience. A key factor is the quality of the parent-child relationship. The Scottish Government has supported the roll-out of evidence-based interventions that support children and their families with behavioural issues, through the Psychology of Parenting Programme ( POPP). To build on the success of POPP there is a need for a range of solid, evidence-based interventions for emotional, behavioural and/or conduct issues where a child would not be diagnosed with a mental illness but could be helped by a psychologically-informed approach. This should include interventions to support children’s parents or carers.
Antidepressant and ADHD prescription items
Between 2014-15 and 2015-16, the total number of antidepressant prescription items dispensed increased by 5% (from 5.8 to 6.1 million items), and the total number of ADHD prescription items dispensed rose by 10.4% (from 105,562 items to 116,556). Dispensing of antipsychotics, antidepressants, drugs for ADHD and drugs for dementia has been steadily increasing over the past ten years. Dispensing of hypnotics and anxiolytics has remained stable, although there was a small decrease (1.6%) this year.
The increase in the number of items reflects the continued and substantial increase in demand for CAMHS. More people have been prescribed antidepressants as a result of the reduction in stigma attached to mental health, as well as better diagnosis and treatment of depression by GPs. Consequently, there is a trend of increasing total cost for antidepressants and ADHD medication. However, due to reductions in drug prices and items coming out of patent, there has been a decrease in cost for hypnotics and anxiolytics, antipsychotics, and dementia drugs.
Guidelines on the prescribing of antipsychotic medications will be informed by best clinical practice and by national Scottish Intercollegiate Guidelines Network ( SIGN) guidelines.  SIGN develops evidence-based clinical practice guidelines for the NHS in Scotland. Its guidelines are derived from a systematic review of the scientific literature and are designed to accelerate the translation of new knowledge into action to reduce variations in practice and improve patient-important outcomes. The guidelines are produced in collaboration with patients, carers and members of the public, and requests for change can be addressed to the SIGN executive team within Health Care Improvement Scotland.
While pharmacological interventions for children and adults are recommended by the guidelines on autism as effective interventions in some circumstances, prescribing decisions in individual cases are always the responsibility of practitioners, in consultation with loved ones and other professionals involved in an individual’s care.
Some children travel out-with Scotland to receive specialist care. While it is possible that, in order to provide the appropriate clinical care, some highly specialist services will always need to be provided out of the country where numbers of patients are very small, this should be minimised where possible. In order to reduce the need for vulnerable young people to travel outside Scotland for their health care and to improve the pathways of care, the Scottish Government has offered funding to support the capital development of a forensic CAMHS inpatient unit. Planning proposals are currently with the NHS.
The Scottish Government is also supporting work on potential mental health inpatient needs of children and young people with a learning disability (intellectual disability) and/or an autism spectrum disorder. In this regard, Action 20 of the Mental Health Strategy is to scope the required level of highly specialist mental health inpatient services for young people, and act on its findings.
Mental health legislation
The Scottish Government continues to work with stakeholders to ensure that mental health legislation works effectively and that it respects, protects and fulfils the rights of service users. This includes implementing the improvements to mental health legislation in the Mental Health (Scotland) Act 2015 and the review of whether current mental health legislation is appropriate for those with learning disabilities and autism spectrum disorders.
8.4 Dementia 
On 28 June 2017 the Scottish Government published its third National Dementia Strategy for the period 2017 to 2020,  with a vision of a Scotland where people with dementia and those who care for them have access to timely, skilled and well-coordinated support from diagnosis to end of life, which helps them achieve the outcomes that matter to them. The third strategy continues to take a human rights-based approach to the treatment and support of people with dementia, and is based on close and ongoing engagement with people with dementia, as well as their families and carers, to ensure they receive the right care at the right time and in the right setting.
The strategy’s priority areas include a continuing focus on Scotland’s distinct offer that everyone newly diagnosed will be offered a guaranteed minimum of one year of appropriate post-diagnostic support, and enhancing the focus on the flexible and person-centred delivery of those post-diagnostic services. There is also a focus on greater integration of home care, and developing palliative and end-of-life services.
The Scottish Government is working with Healthcare Improvement Scotland to extend the improvement and scrutiny programmes currently in place in acute hospitals to non-acute hospitals and specialist mental health in-patient dementia settings. A National Action Plan supports the implementation of Standards of Care for Dementia in Scotland in acute hospital care. 
Over 700 healthcare and social care staff have been trained as Dementia Champions and around 1,000 Dementia Ambassadors have been inducted in social care, with 70% in care home settings. Standards of Care for Dementia in Scotland contains clear standards on therapeutic and medical interventions, including how to manage stress and distress, and on the appropriate use of medication. As part of an ongoing programme of investment in the dementia workforce, the Scottish Government has developed a number of education and training initiatives that consider alternatives to medication, including Psychological responses to stress and distress in dementia; Responding to distress in dementia; and The Pharmaceutical Care of People with Dementia.
The Scottish Government is committed to the implementation of its national knowledge and skills framework for staff working with people with dementia, Promoting Excellence,  and continues to implement its human-rights based Standards of Care for Dementia in Scotland, a framework which outlines in depth the skills and knowledge that health and social work care staff should have depending on the role they play in supporting people with dementia. 
Both Promoting Excellence and Standards of Care are underpinned by the principles set out in in the Scottish Parliament’s Cross Party Group on Alzheimer’s Charter of Rights for People with Dementia and their Carers in Scotland.  Introduced in 2009 in pursuance of the Human Rights Act 1998 and the Scotland Act 1998, the rights set out in the charter are based on internationally-agreed human rights and are intended to promote the respect, protection and fulfilment of all human rights of people with dementia and their carers.
The Scottish Government continues to support the development of dementia-friendly communities throughout Scotland, as well as awareness-raising campaigns such as Dementia Awareness Week. Alzheimer Scotland has designed a logo for business premises, leisure centres, places of worship, schools and clubs as a sign that people are working towards creating a dementia-friendly community. In 2015 the Life Changes Trust invested £3.4 million in dementia-friendly communities across Scotland. A recent review of the projects has highlighted the significant benefits they are delivering to people with dementia, their families and carers, as well as the communities in which they live. 
This activity is framed within the context of health and social care integration, which is significantly changing services and opening up new opportunities to better support people, including those with dementia, in their homes and communities. In addition, the Carers (Scotland) Act 2016, which commences in 2018, aims to ensure that people who provide unpaid care are supported to look after their own health and wellbeing.
In 2011, the Scottish Government launched the Scottish Strategy for Autism,  which focuses on reducing the inequalities faced by people who have autism. It has been reframed into an Outcomes Approach with four key outcomes that aim to ensure that people with autism are able to enjoy their human rights and access to public services without discrimination.
A key part of the strategy is to ensure that the health and social care workforce have an understanding of autism relevant to their role to ensure that people with autism are met with recognition and understanding. To support this, NHS Education for Scotland has developed the Scottish Autism Training Framework and resources. Work also focuses on improving the waiting times for diagnosis and transitions of young people into adult destinations.
Work is underway to develop and consult on the final stage of the strategy, which will see agreed priority actions to be delivered by the end of the strategy in 2021.
8.6 Learning disabilities
In 2013, the Scottish Government launched the Keys to Life strategy.  The strategy has a strong emphasis on human rights and a specific focus on health inequalities. During 2015 a refreshed delivery approach was launched. The key features of this approach were an implementation framework predicated on four key strategic outcomes and a strong focus on cross policy working. The strategic outcomes were arrived at through a thorough review of the strategy content and recommendations. They are rights-based and centred on a healthy life, choice and control, independence and active citizenship.
The implementation framework as a whole is underpinned by detailed logic modelling and delivery set within the context of the PfG. Responsibility for delivery is assigned to Scottish Government policy officials working with strategic partners, Scottish Commission for Learning Disability and the Scottish Learning Disabilities Observatory, plus a range of delivery partners, including third sector providers and specialists such as Downs Syndrome Scotland and PAMIS (who work with people with profound and complex impairments). The implementation framework is linked to and informed by the development of A Fairer Scotland for Disabled People.
Work is underway to refresh the Implementation Framework and take forward priorities beyond 2017.
It is estimated that there are 745,000 adult carers and 44,000 young carers under the age of 18 in Scotland. 
While caring can be a positive and rewarding experience, it is crucial that carers are supported at an early stage to enable them to better cope with the stresses and demands of their role, and to look after their own health and wellbeing.
The Carers (Scotland) Act 2016  will be commenced on 1 April 2018. The Act extends and enhances the rights of carers ensuring that they can continue to care, if they so wish, in better health and to have a life alongside caring. Provisions in the Act include:
- a duty on local authorities to provide support to carers, based on the carer’s identified needs which meet the local eligibility criteria
- a specific Adult Carer Support Plan and Young Carer Statement to identify carers’ needs and personal outcomes, including consideration of the impact on the carer of having one or more protected characteristics (within the meaning of the Equality Act 2010)
- a requirement for each local authority to have its own information and advice service for carers, which must provide information and advice on, among other things, emergency and future care planning, advocacy, income maximisation, and carers’ rights
The Scottish Ministers will also prepare and publish a Carers’ Charter, setting out the rights of carers as provided for in or under the Act.
The Scottish Government will deliver a new package of support for young carers to be rolled out during the course of this Parliament. A ‘Young Carer Grant’ worth £300 annually will be available for young carers aged 16 and 17, or 18 if still at school, who care for 16 hours or more each week and do not currently qualify for Carer’s Allowance. Recipients of the grant will be entitled to free concessionary travel. Young carers aged 11-18 will also benefit from a new bespoke carers element to the Young Scot Card, providing non-cash benefits and rewards for young carers aged 11-18.
Carers make an immense contribution to society and it is unfair that the support they receive in the form of Carer’s Allowance (currently reserved to the UK Government) is the lowest of all working age benefits. From Summer 2018 (backdated to April of that year), the Scottish Government’s Carer’s Allowance Supplement will increase Carer’s Allowance (currently £62.70 p/wk) so that it is paid at the same level as Jobseeker’s Allowance (currently £73.10 p/wk).
The Scottish Government has agreed with the UK Government that any new benefits or discretionary payments introduced by the Scottish Government, which provide additional income for a recipient, will not result in an automatic offsetting reduction by the UK Government in their entitlement elsewhere in the UK benefit system.