Structural characteristics of the LTC system, impacts of the pandemic, measures adopted and new reforms
This country profile brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in Scotland from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Scotland.
Experts on COVID-19 and long-term care in England that have contributed to this report:
PART 1 – Long-Term Care System characteristics and preparedness
- 1.00. Brief overview of the Long-Term Care systemIn Scotland, Long-Term Care is known as social care. This care can take the form of care services delivered in a person’s own home, for example personal care support and meals services, or care provided in the community, for example day care and social work support, to care provided within a care home. Public Health Scotland estimated that in the financial year 2018/19, at least 245,650 people of all ages received social care services. Of those, over 77% were aged 65 and over. Data from the Care Inspectorate Scotland show that at 31st March 2020 there were 1,083 registered adult care homes in Scotland, of which 817 catered for older people. Public Health Scotland (formerly Information Services Division Scotland) data from the Scottish Adult Care Home Census show that in 2017, there were 40,926 registered care home places for adults. This figure has decreased from 42,653 in 2007. Over the period 2007-2017, the number of registered places for older people has remained relatively stable at around 38,200 throughout the period. The pandemic has highlighted the data deficiencies within the care home sector The latest data available for Scotland from a report by Public Health Scotland show that in March 2017 there were 35,989 adult care home residents in Scotland (Source: Care Home Census for Adults in Scotland). For the last two decades, Scottish policy has favoured care provision in individuals’ own homes rather than in care homes. According to the Care Inspectorate data as of 31st March 2019, there were 1,046 registered adult care at home providers in Scotland. A Public Health Scotland report on social care statistics in Scotland estimated that 91,810 people in Scotland received home care for all or some of the year ending 31 March 2019. The same report estimated that at the end of that period, 63% of adults with long-term care needs received personal care at home. Personal care is care associated with personal hygiene, feeding, toileting and appearance. In 2017-18, 47,070 people aged 65+ were receiving personal care funded by the Scottish Government in their own homes (An Official Statistics publication for Scotland).
- 1.01. Population size and ageing context
In mid-2020, the total population of Scotland was 5,466,000, representing 8.1% of the total population of the United Kingdom. The media population age was 42.1 years. The share of population aged 65 or over was 19.3% and the share aged 85 or over was 2.3% (Source: ONS).
- 1.03. Long-term care financing arrangements and coverage
Principal responsibility for providing services to social care clients falls on Scotland’s 32 local authorities. For home care, each local authority has their own charging policy which, together with a financial assessment of the persons income, will determine how an individual contributes towards their care services. Since 2002, anyone in Scotland aged 65 and over, whether living at home or in a care home is entitled to Free Personal and Nursing Care if they need it.
Before entering a care home, the local authority will carry out needs assessment and a financial assessment to work out what care the individual needs and how much they need to pay towards the care home fees and services. The amount a person will have to pay depends on if they fall above or below the capital limits (lower limit £18,000 and upper limit £28,750 as of April 2021) (Source: Care Information Scotland, Capital limits). Care home residents who have capital above the upper limit are classed as self-funders and those who have capital falling below the lower limit are funded by their local authority. Those whose capital lies in between the upper and lower limits receive some help from the local authority and fund the remainder themselves. However, Free Personal and Nursing Care in a care home means that self-funders who are aged 65+ receive a weekly payment towards their personal care (£193.50 as of 1st April 2021). Any self-funder in need of nursing care will also receive a weekly payment towards the cost of that care (£87.10 as of 1st April 2021). Finally, those who are funded by the local authority will receive personal care for free (Source: Care Information Scotland).
- 1.04. Approach to care provision, including sector of ownership
Care at home is either provided by the local authority, the health board (in the case of NHS Highland), by private firms or voluntary/not for profit firms. According to data collected by the Care Inspectorate, as of 31st March 2020, of the 1,046 registered care at home for adults’ services, 495 (47%) were run by voluntary or not for profit organisations, 406 (39%) by private firms, 136 (13%) by the local authority and in NHS Highland 9 (<1%) care at home services were provided by the health board (Source: Care Inspectorate).
Within the care home setting, ownership types are the same but unlike care at home, in Scotland most care homes are privately owned. Specifically, as of March 2020, 680 (63%) of care homes for adults were privately owed. The remainder were owned by voluntary or not for profit organisations (24%), local authorities (12%) and the Health Board (1%).
- 1.05. Quality and regulation in Long-term care
The Care Inspectorate is the regulatory body charged with ensuring that high care standards are met in Scotland. It carries out regular, unannounced inspections of Scottish care homes. Where care fails to meet the expected standards, the Care Inspectorate work with the provider to suggest how improvements in care quality can be made. If a provider fails to improve quality sufficiently, the Care Inspectorate have the authority to close the service down, subject to the decision of a sheriff.
- 1.06. Care coordination
Anyone who is eligible to receive social care services in Scotland has the option of choosing Self-Directed Support for their care. Self-Directed Support was introduced in Scotland in April 2014. This option gives individuals greater control over how they receive their care and allows them to personalise their care in a way that suits them. A Public Health Scotland report on social care estimated that in 2018/19, around 79.4% people used self-directed support to make choices about their care (Source: Insights in Social Care: Statistics for Scotland). However, an Audit Scotland report suggested that the accuracy of data regarding self-directed support required improvement (Source: Self-directed support: 2017 progress report).
- 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages
The Scottish Social Service Council (SSSC) has a statutory duty to keep a register of workers in social services including care homes, care at home and housing support services. It is possible for an individual to appear in more than one category covered in the SSSC register but the most recent data suggests there were 36,661 non-managerial registrants working in care homes, 58,016 non-managerial registrants working in the care at home sector, and 49,295 non-managerial registrants working in the housing support sector.
- 1.12. Personalisation, user voice, choice and satisfaction
In Scotland 80% of the care workforce work for organisations represented by Scottish Care; a membership-based organization that provides support, training and advocates for the predominantly private workforce.
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
- 2.01. Impact of the COVID-19 pandemic on the country (total population)
National Records of Scotland (NRS) publish weekly figures on death registrations where COVID-19 was mentioned on the death certificate as either confirmed COVID-19 or suspected COVID-19. According to this data, as of the 28th November 2021, there have been 12,127 deaths where COVID-19 was mentioned on the death certificate.
- 2.02. Deaths attributed to COVID-19 among people using long-term care
Since May 25, 2020, the Care Inspectorate Scotland (CIS) has reported weekly data on notifications of deaths of care home residents. Care homes are required to note whether COVID-19 was noted as confirmed or suspected on the death certificate.
As of April 24, 2022, the Scottish Government has reported 14,332 deaths where COVID-19 was mentioned on the death certificate. As of the same date, CIS has reported 4,726 deaths of care residents of suspected or probable COVID-19, accounting for 33% of total deaths. 4,151 deaths were reported to have occurred within care homes. Assuming that the number of adult care home residents has remained stable since 2017 (based on Care Home Census for Scotland, 35,898 adults receiving care in care homes in March 2017) the number of COVID-19 related deaths of care home residents represents 13.17% of this population.
At present, the authors are not aware of any publicly available data to identify if any care home staff died because of COVID-19.
With respect to social care provided at home, the authors are not aware of any data to identify if those receiving or providing care at home have died because of COVID-19.
Deaths linked to COVID-19 among people with learning disabilities:
A nationwide data linkage study in Scotland comparing all COVID-19 confirmed deaths of people with learning disabilities from 24 January to 15 August 2020 with a 5% sample of adults without learning disabilities reported a Standardised Mortality Ratio (SMR) of 3.20. SMRs were particularly high for people with learning disabilities aged 18-54 (SMR 6.62) and 55-64 (SMR 16.16) (Henderson A. et al. 2021).
Henderson, A. et al. (2021) COVID-19 infection and outcomes in a population-based cohort of 17,173 adults with intellectual disabilities compared with the general population. BMJ doi: https://doi.org/10.1101/2021.02.08.21250525
- 2.04. Impacts of the pandemic on access to care for people who use Long-Term Care
In August 2020, the Health and Sport Committee of the Scottish Parliament ran a survey to collect views from people who provide, or receive, care and support at home. The survey covered the period 10 August 2020 to 7 September 2020. Over half of respondents stated that their care at home support either stopped completely (33%) or reduced (21%). Respondents reported that in many cases, family members had to step in to provide care. The closure of day centres and respite activities was reported as impacting those receiving care at home. Of those staff who responded to the survey, 61% reported that home care packages changed during the pandemic. Reasons reported included reduced provision of services, suspension and even cancellation of services (The Scottish Parliament, 2020).
Impact on access to health and social care services for adults with intellectual disabilities
UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview, at three time points during the pandemic, have reported that access to a wide range of health services (including primary care, more specialist therapists, and annual health checks) significantly reduced from before the pandemic to the lockdown in the winter of 2020. Access has improved since then up to the summer of 2021, but not to pre-pandemic levels, with more consultations being conducted by phone rather than face to face.
The picture is similar concerning access to a wide range of social care services, including day services, community activities and short breaks, with the exception of support at home which has continued at consistent levels through the COVID-19 pandemic. Reduced access to many health and social care services was evident for a greater proportion of adults with intellectual disabilities with greater needs, particularly adults with profound and multiple intellectual disabilities.
The Scottish Parliament, (2020). How has Covid-19 impacted on care and support at home in Scotland?
- 2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care
Responses to the Health and Sport Committee survey suggested that recipients of care felt an increased sense of loneliness and isolation. Unpaid carers also reported increased feelings of anxiety, depression and mental exhaustion (The Scottish Parliament, 2020).
Impacts on adults with intellectual disabilities
UK-wide interviews with approximately 500 adults with intellectual disabilities across the UK reported that in the four weeks before being interviewed in the summer of 2021: 13% of people said they often/always felt angry or frustrated, 15% often/always felt sad or down, 21% felt often/always worried or anxious, 12% often/always felt lonely with no-one to talk to, and 19% of people said they had a new or worsening health condition. Across all these indicators well-being had improved from previous interviews in winter 2020/21 and spring 2021. In the summer of 2021, 50% of adults with intellectual disabilities interviewed felt at least a little worried to leave the house – this was at a similar level to the winter of 2020/21, reversing an improvement in spring 2021.
The same project included surveys with approximately 300 family carers and support workers of adults with intellectual disabilities who could not take part in an interview. In the summer of 2021, family carers and support workers reported that 14% of people were often/always angry or frustrated in the four weeks before the survey, 12% of people were often/always sad or down, 25% of people were often/always worried or anxious, and 28% were reported to have had a new or worsening health condition in the four weeks before the survey.
In a survey of approximately 300 largely family carers of adults with intellectual disabilities across the UK in July/ August 2021, carers most commonly reported their caring role had affected them in terms of feeling tired (66%), a general feeling of stress (60%), or disturbed sleep (53%), with little change compared to previous surveys in December 2020 – February 2021 and April – May 2021.
The Scottish Parliament, (2020). How has Covid-19 impacted on care and support at home in Scotland?
- 2.06. Other impacts of the pandemic on people who use Long-Term Care
People with intellectual disabilities and autistic people
Apart from impacts of the COVID-19 pandemic on access to health and social care services and the health and wellbeing of people with intellectual disabilities, UK-wide interviews with approximately 500 adults with intellectual disabilities and surveys with approximately 300 family carers and support workers have reported a range of others impacts on people’s lives. In July – August 2021, largely after COVID-19 restrictions were lifted in England, 19% of people with intellectual disabilities with greater support needs across the UK (including people with profound and multiple intellectual disabilities) were reported to be still shielding. Over a quarter of adults with intellectual disabilities reported that someone they knew well had died (or any cause) during the COVID-19 pandemic. In terms of paid employment, most but not all people with intellectual disabilities in paid employment before the pandemic were in paid employment in July/ August 2021, often via furlough or people’s jobs being held open.
No systematic information is available concerning the impact of the COVID-19 pandemic on autistic people without intellectual disabilities in England.
PART 3 – Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
- 3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)
First wave and lockdown
On the 1st March 2020, the first positive case of COVID-19 was confirmed in Scotland. Two days later, the UK Government announced its Coronavirus Action Plan; a four staged collective approach for the UK to contain and respond to the spread of the virus. The main advice given to the public at this stage was to wash their hands regularly with soap and water, for at least 20 seconds.
In the following months, a series of recommendations and guidance on isolating, social distancing and event closures were followed by the formal placement of the NHS on an emergency footing and eventually orders were enacted to ask all Scots to stay at home, as the UK entered lockdown on the 24th March 2020. School closures followed. Towards the end of May, the Scottish Government published its Routemap through the pandemic, outlining a five-phased approach to varying
Between May and July Scotland moved through Phases 1 to 3 of the Routemap. The test and protect scheme was rolled out from 28th May and the new contact tracing app was developed. By August, COVID-19 cases were increasing in certain parts of Scotland and localised restrictions were brought into place. On the 20th August 2020, the Scottish Government announced that Scotland would remain in Phase 3 and they set out updated dates for further changes.
Throughout September more localised restrictions were implemented as cases continued to spread and by November 2nd the new five-level strategic framework indicating varying levels of restrictions that would be required depending on the level of transmission of the virus came into effect.
The roll-out of the vaccination programme was announced in December with care home residents, their carers and frontline health care workers being vaccinated first. The over 80s would follow, along with other groups identified as being at risk of serious harm and death from the virus. By the 15th May, 66.6% of eligible Scots had received their first dose of the COVID-19 vaccination.
Further restrictions were introduced over the festive period and on 5th January mainland Scotland entered its second lockdown. All travel corridors were suspended from 18th January. At this point, the roll out of the vaccination programme was well under way and by 17th March, 44% of the adult population had received their first dose of the vaccine.
The second national lockdown would remain until restrictions began to be eased from 2nd April. From the 26th April, free lateral flow test kits were to be made available to anyone in Scotland without symptoms and Scots were encouraged to test themselves twice weekly.
Level 0 and booster vaccinations
Due to the success of the vaccination roll out, on the 19th July 2021, the whole of Scotland entered level 0. Up until November 2021, the focus of the Scottish Government has been continuing to administer vaccines, including the roll out of booster vaccinations (Source: https://spice-spotlight.scot/2021/11/26/timeline-of-coronavirus-covid-19-in-scotland/).
- 3.02. Governance of the Long-Term Care sector's pandemic response
Health Protection Scotland (HPS) has published specific guidance for infection prevention and control in social or community care and residential settings for frail people and those with complex needs. In addition the Chief Medical Officer has published specific advice about visitors and admissions to care homes (Sources: GOV.SCOT; gov.scot.1; gov.scot.2; gov.scot.3).
- 3.02.03. Measures to support, facilitate and compensate for disruptions to access to care
The Adult social care – winter preparedness plan: 2021-22 sets out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. This includes provisions to maintain high quality integrated health and social care services across cares settings. There has been £62 million allocated for 2021/22 to help with building capacity in care at home community-based services. This funding is for:
- Expanding existing services, by recruiting internal staff; providing long-term security to existing staff; enabling additional resources for social work to support complex assessments, reviews and rehabilitation; commissioning additional hours of care; commissioning other necessary supports depending on assessed need; enabling unpaid carers to have breaks.
- Funding a range of approaches to preventing care needs from escalating, such as intermediate care, rehabilitation or re-enablement and enhanced MDT support to people who have both health and social care needs living in their own homes or in a care home.
- Technology-Enabled Care (TEC), equipment and adaptations, which can contribute significantly to the streamlining of service responses and pathways, and support wider agendas. (Source: https://www.gov.scot/publications).
- 3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems
In August 2020, the Scottish Government commissioned the use of a new web-based tool- The Turas Care Management Tool or Safety Huddle tool – to help monitor the risk of COVID-19 within Scotland’s care homes. The tool provides a central location for all Scottish care homes to record information on infection rates, demand on services and staff testing. The purpose of the tool was to provide early warning signs of emerging trends to allow homes to intervene early.
- 3.06. Support for care sector staff and measures to ensure workforce availability
The adult social care – winter preparedness plan: 2021-22 sets out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. This states that the government are supporting a national recruitment campaign with a focus on social media and a younger audience, and working to establish minimum terms and conditions for existing staff. A budget of £12 billion, an increase of £7 million on last year, is being provided to support the wellbeing of health and social care staff. This includes targeted support to the primary and community care and social care workforce of £2 million.
A workstream will be developed on the wellbeing of those working in social care/social work as part of the new National Wellbeing Programme to be implemented from autumn 2021. The Workforce Specialist Service, launched in February 2021, also provides tailored, confidential mental health support to regulated staff across the NHS and social care workforces.
Up to £48 million of funding will be made available to enable employers to update the hourly rate of Adult Social Care Staff offering direct care. The funding will enable an increase from at least £9.50 per hour to at least £10.02 per hour, which will take effect from December 1, 2021.
The Social Care Staff Support Fund has been extended to the end of March 2022 to continue to ensure that social care workers who are ill with COVID-19, or self-isolating in line with public health guidance, receive their normal income for that period.
- 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings
The adult social care – winter preparedness plan: 2021-22 sets out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. Multi-disciplinary teams (MDTs) within health and social care will continue to play a critical role in keeping people well and independent and delivering the right care at home or in the community to prevent unnecessary hospital admission through accessing a range of health, social care and other community services. Extra funding will be provided to support the strengthening of Multi-Disciplinary Working across the health and social care system to support discharge from hospital and to ensure that people can be cared for as close to home as possible, reducing avoidable admissions to hospital. This includes up to £15 million for recruitment of support staff and £20 million to enhance MDTs this year and recurring (Source: www.gov.scot).
The plan includes funding of £40 million for 2021/22 to enable patients currently in hospital to move into care homes and other community settings, on an interim basis, to ensure they can complete their recovery in an appropriate setting. The Home First approach will be built on through the launch of an improvement programme (in collaboration with the Centre for Sustainable Delivery). The Discharge without Delay Programme will engage teams across the whole patient journey, aiming to ensure all delay is prevented where possible and placing a strong focus on discharge to assess. An additional £2.6 million has been shared between ten health boards so they can continue to develop Hospital at Home services to avoid admissions to hospital and we will work with Health Improvement Scotland (HIS) colleagues to monitor the progress of this work.
- 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector
The Adult Social Care – Winter Preparedness Plan: 2021-22 set out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. Following a review of the existing PPE support arrangements, it has been confirmed that the PPE Hubs and PPE Support Centre, which provide free PPE to providers across the sector where supply routes fail, and to unpaid carers who are unable to access PPE through their normal routes, will continue to operate until end March 2022. For care providers, payments for PPE over and above usual amounts as a result of the pandemic have also been extended to end March 2022 as part of the Financial Support for Adult Social Care Providers (see also Extending PPE access to all social care providers).
- 3.11. Vaccination policies for people using and providing Long-Term Care
COVID-19 vaccination rollout in the long-term care sector
Care home residents were prioritised for boosters, with teams going in to care homes to vaccinate residents and available staff. Thereafter staff were invited to attend other locations in the community to receive their booster vaccination.
By the 29th December 2021, Public Health Scotland estimated that 89.4% of all care home residents in Scotland had received a booster or 3rd dose and 95.1% had had at least two doses. 63.6% of staff had had the booster (or 3rd dose) and 88.6% had had two doses.
Calculating the share of care home residents who have received vaccinations is difficult as there is no complete method to identify all people who live in care homes in Scotland using routine data sources, or staff working in care homes.
Policy on mandatory vaccination for long-term care staff
The UK Government has mandated that all care home staff in England are required to be fully vaccinated. Scottish Care released a statement in June 2021 to say that this mandate had little relevance in Scotland since Public Health Scotland figures released up until 15th June 2021 showed that a very high percentage of care home staff had already been fully vaccinated. It is not Scottish Government policy to make vaccination mandatory for care home staff.
- 3.12. Measures to support unpaid carers
The Adult social care – winter preparedness plan: 2021-22 sets out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. This includes an additional £400,000 into the Time to Live Fund to provide micro-grants to give unpaid carers a break. Local delivery will be supported by funding and working with partners including the Carer Centre Manager Network and Scottish Young Carer Services Alliance. Additionally, £1.4million is being provided to deliver the ScotSpirit Holiday Voucher Scheme which will help low income families, unpaid carers, and disadvantaged young people to enjoy a break over the winter (Source: gov.scot).
PART 4 – Reforms to address structural weaknesses of Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
- 4.05. Reforms to address Long-Term Care workforce recruitment, training, pay and conditions
In April 2020, the Scottish Government announced an immediate 3.3% pay increase for all social care staff in recognition of the vital work they carried out during the pandemic.
To cite this report (please note the date in which this report was accessed):
Lemmon, E. Bell D. Burton J., Henderson D. Hatton C. COVID-19 and the Long-Term Care system in Scotland. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) LTCcovid International Living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6
Printable version of this report:
Ongoing research projects on COVID-19 and Long-Term Care in the United Kingdom:
Acknowledgement and disclaimer:
This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.