A crisis within a crisis: the urgency of change for social care in Scotland.

As we all know what we say at the start of the year often sets the tone for our expectations, hopes, and promises for the year to come. In looking back at previous first of the year blogs there is a remarkable consistency if not similitude to the comments I have made. I could therefore save myself a great deal of effort and get the copy and paste key working and I suspect it would read with an air of authenticity about what we still need for social care in the year to come. Yet this year feels very different.

The word ‘crisis’ is everywhere I read and hear; it’s the word of alarm on many of the lips that I have heard or spoken to in the last few days. This year feels so very different to the previous winters even the last two which although exceptionally challenging felt for many reasons different to the one we are now going through. I therefore want today – perhaps at a bit more length than usual – to focus on the crisis in social care and why addressing that is or should be a primary focus of political and economic priority in the weeks and months ahead.

But to begin with – that word ‘crisis’ is an interesting one. Allow me a moment for a semantic sidestep if you will. Originally, the word ‘crisis’ meant “the turning point for better or worse in an acute disease or fever.” But nowadays its commonest meaning is “a difficult or dangerous situation that needs serious attention.” There is something in the original that I like not least because in its root in the Greek it has a connotation of opportunity and new beginning. A crisis can become a moment when things change, and a new or different direction is taken. I think we are very much at such a moment of opportunity.

The state of the NHS

The media over the holiday period has been dominated by stories about what is happening in the NHS in Scotland. They make unpalatable and alarming reading with long delays in A&E, very high levels of delayed discharge, exceptional occupancy levels in our hospitals, an exhausted, weary and morally harmed frontline workforce, and continual warnings about not accessing emergency and urgent services unless the need is essential and very necessary. The focus on the NHS and its state of crisis is understandable although I would want to stress that the work of all those at the frontline and behind it over the last weeks  and indeed for months has been exceptional and sacrificial of self and time. In the midst of a narrative of breakdown and chaos  I think it is equally important to recognise the brilliance, the quality and the success of what is being achieved every day by colleagues in our health service – not least of which is the fact that well over 95% of discharges from hospital are consistently without delay – saying that does not devalue the impact of delay on those who are stuck in hospital but it affirms the hard work of the practitioners in social work, social care and secondary care. It is also critically important that we do not deny the impact of Covid19 upon our health system. As we have rushed back to normality and to adopt a societal vow of silence about Covid and its continued existence we ignore its ongoing impacts at our peril – not least of which is the impact of Long Covid. People are entering hospital in a highly deconditioned state and with exceptional levels of frailty. As a result, patients are staying longer with a greater degree of required treatment which in turns increases the pressure on wards and staff. And at the end of their stay more people than ever before are requiring social care packages in either their own home or in a care home.  At a time of real challenge our health services are supporting more and more people with less and less staff.

The ‘crises’ facing our NHS have been well documented and commented upon but there is a remarkable link with those challenges which I have often commented upon as afflicting social care. That is not just that social care has added to the issues of ‘delayed discharge’ – to narrow things to that single lens is a serious error. I would go further and assert that in the year to come unless we address the challenges and ‘crisis’ of social care then we will continue to fail to meet and deal with those facing the NHS – a focus on one without the other will simply not work. They are two sides of that perennial same coin.

Social care crisis is a workforce crisis.

Over the years I have written a lot about the challenges facing social care in Scotland and do not want to repeat all that here – although despairingly its truth remains. In reducing challenges to one single factor there is always a risk towards oversimplification, but I do not think it unfair to argue that the single continual challenge facing social care both in residential and nursing care home provision and in the community is one of workforce. I might hear you say that it was always the same – and to a degree that is true. Social care has always struggled to compete with others not least the NHS because of a lack of an equal playing field – but we are now in a situation where we aren’t even playing the same game such is the divergence between sectors.

Again, it is worth asserting here that the exceptional professionalism of the women and men at the frontline of social care has been breath-taking, not least the thousands who remained at risk in caring for others during the early stages of the pandemic both in the community and in residential care. But the fact is that we have lost thousands of those staff due to fatigue, exhaustion and because we have failed to recognise, reward, and remunerate their professionalism both before but certainly since the pandemic. We have also shot ourselves in the foot with self-inflicted wounds such as over-zealous oversight and lack of professional trust and regard. Then this week I have read of Sainsburys increasing the salary of frontline staff to £11 an hour in recognition of both cost-of-living pressures and of the need to compete against other retailers. This is clearly to be applauded in these challenging times but compare that to the value society bestows on the work of frontline carers. And this is a point which needs to be made regardless of whether the employer is a charity, private organisation, or a local authority because after all most of the contracts and terms and conditions for frontline care are set by the State at both national and local level.

A frontline professional carer is required to be registered, to be qualified and trained over a period, to maintain that qualification through further study, to be regularly inspected and monitored and work under a fitness of practice regime etc. All this to a degree is appropriate and right for those who care for and support some of our most important citizens whether as children or adults. But to do all that and to remain motivated in challenging times requires society and the taxpayer to appreciate and recognise that role as vital to the functioning of a modern society – I ask you (even with the enhanced Real Living Wage) does £10.90 an hour cut it? I think not. Not surprisingly people are leaving the sector to work in retail and hospitality. All this is not even to mention the unequal treatment in regards to terms and conditions for the thousands of nurses who work in social care and who are increasingly being attracted to join agencies where they are able to earn so much more money whilst working alongside former colleagues – though you can imagine the impact on your morale by working alongside someone who you know is perhaps getting paid double what you are earning for doing the same shift!

But for social care – even more so than the health service – the situation is worsened by the impacts of Brexit and a thoughtless immigration policy and procedure which has been insensitive to the demographic realities of a Scotland that has both not enough workers as well as an ageing population. We lost thousands of gifted women and men as a result of our departure from the European Union, and they have simply never been replaced (and add to that the hundreds who have left social care to remain in Scotland but to work in retail and hospitality.)

Together with an ageing workforce, issues of gender segregation, the enhanced complexity and volume of social care, huge levels of unmet need in the community, the demotivating use of electronic call monitoring and watch systems, the increased use of fifteen minute visits which make it impossible for staff to care and support someone in dignity, and you have a working context in social care in the community which is at best challenging if not impossible.

‘Delayed discharge’

There has been an inordinate amount of media focus – and no doubt political focus once MSPs return next week – on the issue of people being trapped in hospital when they are fit for discharge. All of us who know this world know that remaining in hospital for longer than you need to is not a healthy option. In response to the growing demand and growing number in such a situation the eyes of the system have turned onto social care as the problem. Well, it is and it is not. There are two main targets within the issue of delayed discharge – the first is that we should be doing all we can to stop people going into hospital in the first place and the second is that as soon as they are in, we should be preparing to get them back to their own home or a homely setting as quickly as possible.

Dealing with the issues of avoiding unnecessary admission is critical. An empty hospital bed will be filled by a patient by the very existence of its presence. Ultimately, we need to be using hospitals less not more and that necessitates treating people as close to their home as possible. An emphasis on local treatment and prevention has been talked about for years and works in some places but requires a massive re-orientation in focus from hospital focussed healthcare to community primary care and social care provision. We have a considerable distance to go down that road, yet it is a journey that is essential if we are to become a healthier community. Too many people are unnecessarily admitted to hospital which not only endangers their lives in the long-term but also lessens their wellbeing in the short term. We need to urgently invest resource in shared social care and primary care models of local support. Care homes which are adequately resourced and staffed are for instance ideal locations for people to be supported for brief times rather than in large institutional acute settings.

At the other end of the spectrum the vast majority of people in hospital today who require a social care package of support are needing to return to their own home but the parlous state of homecare, care at home and housing support means that many charitable and private organisations have handed back care packages, cannot recruit staff and are exiting the sector en masse. There is need for an urgent review of homecare because if we do not get the system right which supports people to remain independent in their own homes then they are unnecessarily admitted to hospital putting yet more pressure on an already strained service. It is worth stating that such reform which requires fair commissioned services, contracts which are equitable and which offers real choice to citizens rather than a one-size fits all model, will require significant resource – the question is as a society are we prepared to finance a preventative approach that values personal choice and independence or to continue to fund an emergency response which is primarily focussed on acute and secondary hospital care?

Lastly in terms of delayed discharge. I have heard it said in recent days that we need to see a return to the old cottage hospitals. Those of us old enough to remember them should be appalled at such a suggestion. There were very good reasons we closed down such units and places and that was that despite the dedication of local staff in many of them that there were too many which had become places to maintain and house older people with degenerative illnesses such as dementia. When we began to focus on care homes as places of long term care for our citizens the emphasis was on creating non-institutional settings and places where people could be rehabilitated and supported in a better environment more conducive to personal care and support and shared living.  At their best care homes have become such places where if adequately resourced and staffed an individual can live a much better quality of life than they could ever achieve in a hospital.

In addition, there has been a huge change in the nature of care homes in the last decade and a half to the extent to which many have become effectively local hospitals and hospices in everything but name. This is especially the case in those homes which offer interim care places which allow someone to be discharged from hospital and to be supported and re-abled to continue their journey home after a few weeks stay in a care home or indeed to move onto another care home of their choice. Believe you me being supported in such an environment in your journey of care is a much better choice than being stuck in an acute hospital with stretched services, exhausted staff and a constant flow and change to say nothing of the risk of infection and deterioration because of lack of mobility and movement.

 

We need I think to have an emergency and urgent response to the whole health and social care crisis that we are facing. There is a moment – even a passing one – for opportunity and collective and collaborative change. I get tired as frontline managers, staff and practitioners struggle with the issues facing them of reading and hearing the constant political fighting over these issues. I’m not naive – I know the role of political parliamentary opposition is to hold government to account, to challenge and persuade the electorate that things are not working. But when does the role of a politician become one of civic responsibility which overcomes party political interest, and which necessitates working in collaboration with others with whom you strongly disagree? I think that that moment has well and truly come for the health and wellbeing of our nation. And so, my most forlorn New Year 2023 wish is that in the spirit of a national emergency (regardless of the reasons for it or from whence it has come) we can work as politicians, policy makers and practitioners in a spirit not of mutual one-upmanship but shared solidarity to address the real concerns of life and limb our health and care systems are now enduring. And yes, I still believe in Santa Claus.

We are at a truly critical phase in the dis-ease affecting health and social care services in Scotland, will we use this crisis to collectively work together to achieve lasting change or rather will we be back here next year with a similar blog spouting the same concerns and challenges? I very much hope it is the former because one thing is clear and that is that these are not simply winter pressures but a crisis for all seasons.

Donald Macaskill