Tomorrow is Mental Health Day which provides us all with an opportunity to reflect on issues of mental health and ill health.

On Monday last I read of the launch of a report by the Mental Health Foundation (MHF) on the stress of mental health impacting on our workforce. MHF has called for the establishment of a Future of Work Commission which it claimed could help ensure post-pandemic labour practices support mental wellbeing.

One of the few positives of the pandemic has been an increased awareness  and appreciation of issues of mental health within the workplace.  However, MHF argued that more needed to be done and their senior policy lead Toni Giugliano told the BBC that:

“Poverty, job insecurity and under-employment are among the root causes of poor mental health.”

A very long time ago I was involved in research on the extent to which one’s occupational role status impacted on your sense of mental well-being and the relationship between your role being under pressure and any  burnout or stress you experienced. In general terms the research showed that the extent to which you are valued by others in the work you do, the societal value of your role in the community, played a very significant part in whether you experienced burnout or stress. If you do a job which others respect, value and affirm then it was a huge contributor to feeling healthy and well about yourself. The positive benefit of a valued role was especially the case in situations where the job you did was under pressure and when things were tough or hard. The opposite was also the case – namely that is if your role was not valued by society or others then that heightened your sense of stress and mental health challenge.

Such an awareness together with the increased knowledge of mental well-being in the workplace has made me reflect on how we regard the role of the professional carer. During the pandemic were you to consider the value we placed on social care workers you at  best would have evidenced a fluctuating appreciation.

Way back in March and April 2020 along with many others I was appalled at the way in which frontline social care staff were turned away from the priority shopping queues at some of our large supermarkets – because they were not employed by the NHS but were ‘just a carer.’ Then things began to improve as the Thursday clapping on our doorsteps began to include care staff not least as the sad statistics of loss in our care homes gained more media attention. But then we went  into the summer and autumn and the clapping fell into silence.

Politicians then began to talk up the role of care and at least during the Scottish election there was an enhanced awareness of the need to reward and better remunerate frontline care staff.

But more recently things seem to have taken a backward step as we saw frontline homecare staff struggling to get priority treatment as they tried to get hold of petrol in order to drive their cars to do their job. Combine that with the unwillingness to ease immigration rules to allow care staff to be recruited and you get a very different perspective on how we do or do not value frontline care work and carers.

Why does all this matter? A huge amount if as we have stated above that there is a close correlation between the way society values the job you do and your own self-esteem and mental health. It is one thing to burst your gut, to put your health on the line day in and day out as our care staff have done for so long and way before COVID-19 if you feel others value you and hold you  in esteem – it is quite another thing if you are held with little regard, given minimum thought and respect and paid inadequately for the work you do. This is often seen in the perverse debate which considers the job of care as ‘low-skilled’ instead of the professional, multi-skilled role it is. Too many people think of a home carer as someone who does the shopping and cleaning for another forgetting that it also carries with it skilful moving and handling, medication management, personal care, end of life and palliative care, mental health support and so much more.

As we consider mental health awareness as a whole society and community I think we urgently need to re-evaluate how we view frontline care. Those who give of the best of their humanity to care for and support another human being, those whose task it is to enable others to achieve their best and fullest potential, should not be viewed with such dismissive disinterest and disdain as they often are. Frontline care is a mirror of our humaneness at its best; those who care – whether in paid care or not – are the best of us.

If we are to address the very real workforce challenges facing social care in Scotland at this time – then we would do well to start with giving proper respect and status to those who care. If we do, then the self-esteem and integrity of the carer will be advanced and we just might avoid the appalling burnout and work related mental distress we are witnessing in increasing amounts. That’s something worth striving for not only on Mental Health Awareness Day but every day.

 

A few years ago, when I was attending a conference on technology one of the speakers made the comment that access to the internet and WIFI should be considered as just as important as the right to water, heat, and electricity. He argued that digital access should be viewed as a public utility. I was reminded of that observation today because this is the annual United Nations International Day of Older Persons. The 2021 theme is “Digital Equity for All Ages” and it focusses on the need for access and meaningful participation in the digital world by older persons.

I’ve written in this blog quite a few times about the role of technology and how critical it is for the current and future delivery of social care. However, at times I think the experiences of discrimination and exclusion which many older people come across in their day-to-day living is exactly what they encounter in the digital world. Despite some significant strides in the last few years, I still believe that age discrimination, exclusion and lack of priority is the reality when we consider the new ‘public utility’ of digital as far as older people are concerned.

There is absolutely no doubt that older people experience digital poverty and exclusion more than any other population group both in Scotland and internationally. The data speaks for itself.

Office of National Statistics data from 2018 show that the over 65s make up an increasingly high proportion of internet non-users. In a major study 79% of non-users in 2018 were 65 or over, with 55% over the age of 75. This compared to 25% and 36% respectively back in 2011. So effectively as the rest of society is becoming more connected and digitally empowered older people are becoming less so.  A similar survey by Lloyds Bank, the Consumer Index 2020 Report, showed that 77% of over 70s had very low engagement compared to just 7% who have high digital engagement.

We have talked about digital exclusion and poverty for some time. We know well some of the main characteristics which prevent individuals of all ages from having access to technology, chief amongst them being socioeconomic background, poverty and other discriminatory characteristics. Indeed, there is wide appreciation that there are some key factors which are involved in digital exclusion including access, both physical and financial; skills, confidence and motivation. Recently Inspiring Scotland published an excellent report reflecting on the Covid pandemic and articulating the importance of addressing digital exclusion. They stated:

‘Overall, it is clear that tackling digital exclusion is essential for individuals and communities to thrive and to ensure that everyone in society receives the opportunities needed to succeed in today’s modern world.’

The pandemic has shown just how much we have become dependent on digital access and skill regardless of our age. At our best we have used technology to connect and ensure that social and personal relationships have been maintained. There has been some really positive work, not least the Connecting Scotland programme. But on their own such innovations and initiatives are insufficient and without real strategic co-ordination the factors which act as barriers to older age participation and empowerment in relation to technology and digital will become embedded. The absence of older age in many of our national strategies and frameworks is particularly concerning, for instance the ‘Renewing Scotland’s Full Potential in the Digital World’ consultation report of late 2020 did not explicitly mention older age.

For me much of the debate around older people and digital access has to be seen through a human rights lens. Article 27 in the UN’s Universal Declaration of Human Rights states that “Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.” Given that so much of modern culture is now online, given so much which enables an individual to access information about services and supports, about community and connection, are now almost exclusively online, then access to the internet for all citizens is a mark of civic obligation and responsibility and therefore becomes a human rights issue.

Technology and digital matter for many reasons but at their heart is an issue of empowerment of the individual’s personal autonomy and the enabling of their full citizenship and participation in community and society. If we continue to discriminate – and discrimination is not just active exclusion but is also a failure to positively prioritise one group or another in order to level the playing field – then we will continue to build the barriers that limit the ability of older persons to gain the freedom and fullness which digital inclusion potentially brings.

For an older person taking control of your life in 2021 Scotland requires a degree of digital literacy and confidence. That does not just happen – it needs to be resourced in the same way that access has to be resourced whether it is by supplying devices or ensuring that there is adequate connectivity in all places and for all people. Being in charge of your digital world promotes personal independence and reduces dependency – that in itself should encourage investment in technology for all ages.

I really do worry that we are treating older individuals as people to use technology on or for – especially in the social care context. The opposite should be the case. Giving access to information, enabling personal self-management whether it be of finance or health, is about enabling an individual to be as fully independent as they want to be and helps to reduce reliance upon others and unnecessary dependency. There are some tremendous resources out there which help older people become digitally confident such as those from Outside the Box.

But there is also a need to challenge technological and digital attitudes, behaviours and design which serve to disempower older individuals. Just this last week in the US Amazon announced a new subscription service called “Alexa Together,” designed for families with ageing family members who are still living independently, but who may need extra support. It builds on the existing product, Alexa Care Hub, by adding on new protections, like an urgent response feature and access to a professional emergency helpline. Starting early next year, Alexa Together will also make it possible for multiple people to provide support for a loved one — which is useful in situations where siblings may split the duties of caring for a parent, for example.

Now I would be the first to acknowledge that there is real potential in such apps and devices – for instance it can allow carers to set up reminders, give access to music etc, and allow hands free calls and communication.

However, I do yearn for a situation where as much design focus, resource and attention were given to enabling independence for older people as to potentially watching and safeguarding and sometimes passive inactivity. Where is the investment and ingenuity in enabling older persons to be more self-reliant and truly independent in this digital age? Where is the work on accessible, one touch devices etc. It is out there but only on the margins.

The UN Day is about Digital Equity for All Ages and that means putting older people at the heart of design, listening to their designer voice and choice, and being less protective and paternalistic and more empowering and enabling. Digital and technological innovation for older age must tackle stereotypes, prejudice and discrimination associated with digitalisation, taking into account the right to personal autonomy.

We have a long way to go to addressing digital exclusion and making inclusion more than just about having a digital babysitter.

Donald Macaskill

Social care has been much in the news in the last few months, and it will continue to be so – not always for the right reasons. For many people social care support is something they don’t often think about – that is until the services and supports are needed whether because of accident, degenerative illness, and disease or simply the realities of ageing.

In Scotland we have a very clear system for accessing social care support – at least theoretically – in practice it can be a bewildering world of confusion and lack of information. This is especially unhelpful because when people are at the point of choosing social care support provision they are often in a place of crisis and fatigue. The fact that things can go wrong, that information and choice is not always clear and that sometimes an individual or family just need someone to speak for them, are sadly all too common.

Over my professional life I have always been a supporter of the role of advocacy whether that be for those who use care supports to be able to self-advocate or for others to use professional advocacy at specific times of crisis and disagreement. For a period of time, I was part of the Board of an advocacy charity and got to know the life-changing work which a good advocate can undertake and the amazing difference that can result for someone when there is a person in their corner to speak for them and to fight their cause.

The definition of advocacy is the act of speaking on behalf of or in support of another person, place, or thing. An advocate is there not to speak for themselves but to represent another person. The word advocate has an obvious legal overtone and that is no accident because it comes from the Latin ‘advocare’ meaningto “add” a “voice.” The advocate adds their voice of support to a person. But the Latin word also carries with it the sense of ‘summoning’ – calling support to your side to make the change that is needed. Advocacy is not just talking – it is also about action; it is not just a vocal contribution but an active engagement that makes the change happen which someone wants and needs in their life, not least to protect their human rights, individuality and dignity.

There are many organisations which provide advocacy services across Scotland and you can find out more detail and support from groups like the Scottish Independent Advocacy Association.

In Scottish law there are also certain instances where an individual has a legal right to access advocacy services not least as part of the provisions of the Mental health (Care and Treatment) Act. It should be stated that the MHCT Act declares that people who are covered by the right to advocacy are those who have a mental health issue including those with a learning disability, autism or dementia. There are other specific instances, for instance for children and young people, and the new Scottish Social Security Act, where there is a right to advocacy in law.

My problem is that the right to advocacy simply is not being evidenced in practice and that as it stands the right to advocacy does not go far enough especially for those who access social care supports.

We are still celebrating World Alzheimer’s Month and many of those living their lives with dementia are individuals who would benefit from the automatic right to advocacy. The vast majority are unaware that they may in technical terms have such a right. They would benefit from being able to challenge practice which limits their choice and control, their abilities to live independently for as long as they can, and to challenge the financial choices and options they are often presented with.

Scotland has brilliant social care provision on paper but the reality falls far short of the dignified, rights-based, person-respecting social care supports we would want to see in place. If you are lucky enough to have someone in your corner fighting your case then you are doing well. But if you are not – and sadly we are still in a situation because of lack of fiscal priority and blatant discrimination where people have to ‘fight’ for their social care rights in the first place – if you are voiceless, have no family or close supports – who does the talking for you? You need and deserve an advocate.

The creation of the envisaged National Care Service gives us the opportunity to sharpen up and tidy our existing social care legislation, not least of which is the Social Care (Self-directed Support) Act. We should use this time as an opportunity to create equality of advocacy for every woman, man and child who find themselves needing to use social care support regardless of mental capacity or physical condition. We should create an automatic right to independent advocacy for anyone who needs it in Scotland’s social care system. Not everyone by any means would use or need such protection, but for those who might and do it would be a significant step forward in enshrining the human right to social care support as part of our national human rights framework in Scotland.

A society should be defined by the extent to which it protects the voiceless and those with no ability to assert, protect and advance their own human rights and those of others. For some that defence comes in the advocacy, passion, and voice of another.

A few years ago when I was more involved in the world of advocacy I came across a fantastic book of poems, ‘Absent Without Leave, Invisible When Here.’ by Jo McFarlane which was developed to support the work of Dumfries and Galloway Advocacy, and for me one of the poems captures the essence and passion of advocacy.

Advocacy NOW!

In the future

when it’s fashionable to listen

Everyone will have a voice –

the disadvantaged, disillusioned

All will have a voice

 

Not just to say what’s wrong

or could be better,

but to celebrate what’s good right now

 

In the future

people won’t be threatened by dissent.

We’ll welcome opposition to the status quo

 

In the future

when all voices speak as one,

we’ll challenge the hegemony.

We’ll seek the truth that speaks its name

regardless of authority or strength in numbers

 

In the future

we’ll drown out the volume,

separate the essence from the noise

 

In the present

we’ll keep fighting for a future

in which ALL shall have a voice

 

http://www.dgadvocacy.co.uk/wp-content/uploads/2018/02/SIAA_AWOL_poetry_by-Jo_McFarlane.pdf

 

Donald Macaskill.

The 1st of September is officially the start of autumn and yet where I am sitting now it feels as if we are amid a summer of sunshine – and allegedly the sun and warmth are set to continue for at least another week. As the adage goes now the schools are back the good weather starts. The turning of the seasons has always been of interest to me, not least that move from summer to autumn then onwards to winter.

It has been a strange summer. We have gradually seen Covid restrictions ease in most of society with heightened anticipation and dependent on where you are for some people a full thrust into reverse gear back to past actions. For the majority some degree of ‘normality’ has been possible but for many not least in our care sector restrictions have remained and a sense of the normal has still been out of reach.

I have taken some time off over the last few weeks and in most instances have been seeing family which has meant that I have been to almost the southernmost part of England and far north in Scotland. As I have travelled and talked to people, I have noted a real divergence in attitudes and behaviours during this Covid summer. This is in part because of the diverse messaging from governments and politicians and dependent upon the extent to which Covid has impacted on local communities and people. The lack of consistency in public health messaging from politicians and scientists has been singularly unhelpful and at the very least the failure to mandate mask wearing in public places in parts of the UK will doubtless be the object of hindsight regret.

The diversity of response and behaviour was much on my mind as this week I travelled to Edinburgh for the first time in 18 months. Even a partial return to my old work routine was a strange revisiting of behaviour. I was struck by the level of anxiety that consumed me in a journey which I used to make three or four times a week. I was aware of my physical reaction every time someone who did not wear a mask got on the train, every time someone started to cough beside me or when I saw someone behave in a manner which I would probably have ignored two years ago. That’s to say nothing of the crowded busyness of tourist filled Edinburgh.

When I got back to the cocoon of my own space, I reflected on why I had been so anxious and concerned and in truth it was the same for many of the moments over the last 18 months when conditions changed, lockdowns ended, and restrictions were relaxed. For many folk it has been hard to change the routines of self-protection and preservation.

It was in the context of such thoughts this past week that I have read and watched as both scientist and politician have consistently increased the tenor of warning and that discussions on further restrictions have started to appear.

Anxiety is becoming commonplace as people witness the growing number of cases and the rise in the number of people being admitted to hospital. Scotland has just yesterday recorded over 6,800 positive cases and one of the highest test positivity levels. Against all this we are told that though people are becoming infected the impact is not as severe because of vaccination. But this week we have also read that the immunity granted by vaccination is depleting at some pace, down to 67% for those of us who are Astra-Zeneca double dozed after several months. Hospital cases are rising and at times I fear people are immune to that soundbite, forgetting that a case in hospital is not just someone feeling slightly unwell, but someone admitted with serious illness. And then the data on death and mortality which is thankfully very low compared to earlier in the pandemic – but I do have concern that our reaction to the daily number of deaths is displaced from the compassionate stance we had when we were losing more people every day. For each person there is a life, family and connection shattered and lost.

Looking at the data for care homes we see there are in the past week 97 staff who have tested Covid positive compared to 56 the week before. In the week to 22^nd August there were 42 new Covid cases amongst residents, 8 more than the previous week. The number of outbreaks in care homes has also risen sharply in the past week to 47 which is the same number as in mid-February. All the data shows that the majority of both the recent resident and staff cases have been double vaccinated.

We seem to be in a place where the seasons are turning and anxiety rising, where the warmth of the summer sits uneasily with the coming chill, where warnings are rising and concern increasing.

And while all this is going on in the last week, I have held countless conversations which have been dominated with a sense of deepening crisis and fear for the sustainability and stability of the social care sector.

We are amid what feels to me like one of the worst workforce crisis the care at home and care home sector has faced for many years. There are more and more care providers who are struggling to recruit staff because there is so much competition from other sectors such as hospitality. The absence of incentivised reward and adequate remuneration which truly values the skilled work of care is not helping at a time of acute job competition. Added to this we have seen a dramatic drop in the ability of social care providers to recruit from outwith the United Kingdom. Now lest someone immediately says we should be using our own population – I would say do the sums! – we are a nation that needs the creativity, innovation, and insight of those who come to this country and become our community. We have an ageing workforce with a population which is older in greater percentage than any other part of the UK. We need to urgently address the exhaustion and tiredness of our care sector staff and to provide support in very practical terms as we move into autumn and winter.

I do not know what the future will bring but I am more than aware that we need to work with the fear and anxiety which is palpable around us in many quarters. A false positivity will not help address the reticence of people when faced with the fear of debilitating illness and the rising numbers of Long Covid. Covid19 is with us for some considerable time to come and glib phrases like ‘we need to live with it’ will not give the re-assurance needed to those who are fearful and cautious, most especially in our care sector.

Throughout all this the ability to listen, to empathise and to work collectively in authentic partnership must be at the heart of how we move forward both as a care sector and as a wider community.

The brilliant Maya Angelou has long been a personal favourite and many of her poems are poems of ‘transition’ – they occupy the liminal spaces of life between love and hardness, emptiness, and joy. One such is her poem ‘Late October’ which describes life as a cycle and uses the seasons of the year as a metaphor for life describing the ‘special insight that lovers have into endings and beginning.’

Life as we have known her has disappeared into the summer mists, from our future comes the hope of a new way of relating one to the other, it is a hope we build by addressing the fear and anxiety of the moment, it is a hope we nurture by walking with those who fear rather than abandoning them. I know not what the weeks will bring and hope that the pandemic will come under control once more, but the price of ‘freedom’ can never be at the cost of the harmony, hope and peace of others.

“Only lovers
see the fall
a signal end to endings
a gruffish gesture alerting
those who will not be alarmed
that we begin to stop
in order to begin
again.”

 

Donald Macaskill

Last Tuesday I was invited on to Radio Scotland to talk about the benefits of ‘Virtual Reality’ for older people in Scotland especially in our care homes. As regular readers of this blog might know I am someone who has long held an interest in all things technology and digital, not least artificial intelligence and robotics.  Both during and after this week’s programme I began to reflect on the extent to which we have not fully tapped into the potential of VR for both older people living in care homes but maybe especially for those in our communities. This will be an issue which we will be considering in a lot more depth during the Scottish Care hosted virtual Care Tech 4 event which will be held this coming Thursday and Friday. It promises to be a great couple of days which folks can drop in and out of with a range of up-to-date demonstrations, presentations and exhibits as well as fascinating panel discussions. For more details see https://scottishcare.org/care-tech-4/

But for now, as my title asks should we care about virtual reality?

A lot has been said and written about VR over the years not least about its role in gaming technology, of which Scotland is one of the major centres of innovation, development and invention. There has been less written about the benefits and drawbacks of VR for the care and support of citizens regardless of their age. Indeed, there have, I believe, been around 5,000 academic articles in the last three years alone about VR but few of these have been about the use of VR in our care and support sectors.

We can make some general conclusions from the research that has been done to date along with anecdotal evidence in Scotland which in broad terms suggests that VR is of real benefit, in some instances of very significant benefit. One of the reasons research suggests that VR is an asset is because of the immersive interaction capabilities which VR enables and allows.

In my experience I think we can broadly suggest there are the following positive benefits of using VR in care homes and in someone’s own home:

Firstly, there are clear health benefits to be gained in terms of exercise, increased physical mobility and movement. So, the recently developed innovation from an Edinburgh entrepreneur working with local care homes has helped individuals to remain mobile and to exercise. See https://www.edinburghlive.co.uk/news/edinburgh-news/edinburgh-entrepreneur-uses-virtual-reality-21228219and https://www.digitechtive.co.uk/care-home-vr

Readers might also be interested in the work of the Norwegian group Motitech which enables people to exercise whilst re-visiting parts of the country which they might be familiar with and evidences real positive outcomes re increased muscle strength, balancer and breathing.

More research needs to be undertaken in this area because studies have tended to focus on rehabilitation and physical function including gait, balance, falls prevention and pain management. They have also tended to focus on settings such as care homes where there is support in their use but the real potential future benefit for physical health will undoubtedly be in the community and ensuring people can remain as independent for as long as possible.

VR in any of its formats is not a panacea but studies are detailing increasingly significant benefits especially if used as part of a wider programme os health and wellbeing, rehabilitation and exercise. See https://www.jmir.org/2020/6/e17331/

Secondly, there is growing evidence to suggest that the use of VR can improve psychological health and well-being. The use of VR in the support and care of many people with dementia has led to a reduction in agitation, improvements in behaviour which challenges, and a reduction in the use of psychotropic interventions.

Thirdly, the use of VR as a memory tool has heralded real benefits. Used well it can bring people back to experiences and encounters, to places and events, which have been significant in their past and which can help in terms of cognitive recall and stress alleviation.

Fourthly, VR has great strengths as an educational tool, enabling its immersive approach to support any individual regardless of their age, to gain new understanding and knowledge. Contrary to popular opinion and stereotype many older people both in care homes and in their own homes, thrive on new experience, learning and insights.

Lastly, they enable people to interact and be in touch with people they know or those who they might want to get to know. Whilst pad technology has been dominant in maintaining contact especially during the pandemic there is a real potential in the use of VR.

Now there are clearly challenges but these are capable of being addressed and overcome. Wearing a headset for too long can cause confusion or headaches; there is an importance of being aware of factors which might impact balance and hearing. There needs to be an emphasis on adequate support and maximising accessibility for individuals with reduced cognitive abilities.

But perhaps the biggest challenge for the use of an VR is cost. Whilst basic headsets are now retailing for below £30 some devices can stretch into the 1000s. More pragmatically excellent headsets can be purchased as part of support packages for the low £100s. Nevertheless, there is a clear fiscal cost both in equipment and in the support needed for people to sue them to their maximum benefit. Therefore, when we are designing and developing services and supports, we should now as a matter of priority be considering the cost benefits of using VR alongside a whole suite of other technologies.

Doubtless the above and many issues will be explored during CareTech4 and throughout Scottish Care’s work on technology and digital.

Technology and VR especially is here to say – it is too important a tool to be left to gaming alone – we really need as a whole community to start caring about VR.

Donald Macaskill

I crossed one of my favourite bridges yesterday – one which has a long resonance within my experience. After what can only be described as a stormy crossing this morning I am writing from Skye and my family’s croft in Dunvegan. I’ve said before in this blog that Skye has a special place deep inside me no matter how far I am from its physicality, so it is good to be up even for a couple of days. The Skye Bridge is well known – synonymous with a struggle of a community determined not to have to pay exorbitant bridge tolls and who carried out a successful campaign in the late 1990s, one which belied both court and parliament.

Bridges have long fascinated me – probably since my late uncle showed me his signature on a bridge over the river Hamara in Glendale, Skye because he had been involved in building it. As a child at the time, it seemed to me to be huge but in truth it was but a few feet in length. But the idea of something which brought you from one side to another, something which you could build to provide safety and passage, fascinated me from that moment on.

On Monday last the Scottish Government published their consultation on a National Care Service. I will no doubt make further comment on its contents and proposals in another blog or space but for the moment its words and ideas are cogitating inside my head! But what has fascinated me this past week isn’t so much the vision of the future but the ‘how’ – how do we get from where we are now in terms of social care support delivery in Scotland to the vision or prospect which is held before us in both the consultation and in other proposals which are beginning to emerge in civic society. I think reflecting on that ‘how’ is important because it will either help to achieve the vision or hinder it.

I spoke to the AGM of Scottish Care members a couple of days ago and I heard there and reflected upon the concern of many that the next few weeks, months, and years will be ones of real importance. Getting from where we are to where we want to be involves planning and preparation, focus and concentration. I know that all too well. Climbing a Skye mountain is a challenge in itself – obtaining and developing a vision for how you see the future of social care is an equally arduous task – but as with any climb it is both the preparation for the climb which is essential and also the descent that often causes the most harm and poses the greatest risk. Having a vision is all very well but moving towards that future vision is where risk and harm can really happen.

That is where I feel the image of the bridge comes in. A bridge is not an incidental or accidental combination of brick and mortar, steel and structure, but the fashioning of materials for a purpose which entails design, calculation, and precision. Too often we rush to get to the other side without thinking about the importance of the route we travel or what we use to get us there.

There is such a critical importance that all of us involved in social care plan our next steps with care and mutuality, be we people who use support or frontline workers, managers or owners of care services, trade unionists or politicians.

We need to think of how we support and nourish our workforce who are tired and drained so that they stick with it and continue to dedicate themselves to the art of caring. We need to stop the blame game for care providers and work together to create a future worthy of our communities of compassion. We need to bestow trust upon professionals delivering our care home services rather than hauling them before investigations and oversight, scrutiny, and inspection. We have to chase away the falsity of infection prevention practices which negate human living by treating a care home like an acute infection unit. We need to work with every sinew to build confidence and remove fear so that we can urgently return to the normality of care home living. We need to allow people to take risks, including the risk of acting in ways which may harm themselves if it is their choice with capacity.

We need to think about mutuality not as an airy concept but as a practical, day to day reality where the professionalism of one group is valued, appreciated, and affirmed by another. We need the false dualities of care and health to become entwined in a regard which puts the person at the centre and treats them not as cared for or patient, but as citizen and director of their living health and wellbeing. We cannot wait for a reform to commissioning but must end now the obscenity of 15-minute visits and the penalising of frontline staff. And so on and so on…

One of my favourite poets is the American Emily Dickinson. She led a secluded and quiet life, and her poetry was unconventional both when it was written in the 19^th century and for some still now. She is considered by many as one of the greatest female poets. One of her commonest motifs and images was that of the bridge. Her most famous bridge poem is this one:

Faith—is the Pierless Bridge 

Faith—is the Pierless Bridge

Supporting what We see
Unto the Scene that We do not—
Too slender for the eye

It bears the Soul as bold
As it were rocked in Steel
With Arms of Steel at either side—

It joins—behind the Veil

To what, could We presume
The Bridge would cease to be
To Our far, vacillating Feet
A first Necessity.

Dickinson’s poem is not primarily about religious faith though uses the metaphors of faith traditions. It imagines a sceptical explorer crossing a bridge (possibly the Niagara Falls Bridge). It is a bridge without piers – a suspension bridge – it extends from what we see to what we do not see. It connects what we know to the unknown. It is not a wobbly wooden planked bridge but as one commentator has said is personified as a mother gently rocking her child (the soul) with arms of steel.

The way we cross the bridge, the way we move into the future will determine what is on the other side as much as what we have left behind. So too I suspect it will be with the creation of a new way of doing and being social care. In our creation of a new model or new systems we have to characterise our behaviour as one of care, bestowing autonomy and choice, nurturing humanity and dignity, and fulfilling rights and equality. We can walk with care and compassion, treading a bridge which brings renewal, or we can ignore the reality of the present. To achieve all this, we must have critical and urgent regard to the crisis of the present time and social care in Scotland has I believe rarely been in such a state of multiple crises.

The making of the future is built upon the changing of the present. You cannot build a bridge you expect to walk over by pulling up and destroying the planks on which you walk.

Donald Macaskill

Three weeks ago, I wrote a blog on the nature of vulnerability – both challenging the misuse of the word and also suggesting the need to develop a more positive view of vulnerability. With a degree of synchronicity and similitude, I have been having comparative conversations with clinicians and colleagues in the last few weeks over the concept of frailty.

Frailty has been a key concern for the care sector for many years. Over that time there has been considerable discussion about its definition, what it means both physiologically and psychologically and how relevant it was as a descriptor in the support and care of individuals.  I was therefore delighted to read a piece in the last few weeks by the respected clinician David Oliver which confirmed both my own unease with the term and why it is important that we reconsider our views of frailty.

In that paper Oliver reminds us of the uncomfortable debate in spring 2020 in the midst of the first Covid wave, on the use of the Clinical Frailty Scale (CFS) as a tool ‘to triage, target, and potentially ration scarce intensive and high dependency care.’ With many others I was critical at the time of the use of such a tool as a proxy for individual and person-led clinical decisions and the dangers of age discrimination which might result.

It is important in any debate on frailty to recognise that it has positive dimensions to its usage. As Oliver states:

‘in over 75s registered with NHS practices, severe frailty as defined by an electronic frailty index is associated with far higher risk of hospital admission, death, or care home admission in the following 12 months. People with frailty have less functional reserve and are far more likely (with or without covid-19) to present with immobility, falls, confusion, or generalised failure to thrive, or to get stranded in hospital or experience acute loss of function. Those in care homes, or who have dementia or are receiving home care or post-acute rehabilitation, will often be frailer and older.’

As a general term, therefore, there are clear benefits in being able to use models which can be early predictors of the benefits of additional support and intervention. As a preventative assessment measure such frailty tools are invaluable in achieving both better outcomes for the individual person and in reducing the economic health costs for the rest of society brought about by unnecessary hospital admission.

But the term is not neutral and can be used sometimes with inconsistency and contradiction. Indeed frailty is a term and concept which as researchers like Archibald et al have shown is not widely understood by the general population and is negatively viewed as a descriptor by older people themselves. They argue in their research that the use of the term may actually serve to harm key public health messaging.

A critical dimension of the care and support of older people is to enable individuals to maximise independence either in their own home, in the community or in a care home. Most associations on frailty relate to a loss of independence predominantly due to challenges with mobility and a loss of control over one’s environment. Frailty clearly both at the popular level and clinically carries with it negative connotations.

There are a couple of points in this extensive debate which I want briefly to make in this blog.

The first is that at times there can be too great a stress upon frailty seen as physiological decline without a resultant emphasis upon psychological, emotional and environmental changes and challenges, and

Secondly, I wonder if it is time to collectively replace the concept of frailty with a more positive modelling based on how we should be enabled and assessed as ‘ageing well’?

Turning to the first issue. There is now a wide professional acceptance that frailty is not solely about physical decline, either of mobility or other functions. There is an appreciation that we need to have and adopt a holistic understanding of frailty. An individual’s circumstances and the constraints on their independence are a product of many factors, including their physical environment, their psychological well-being, the extent and degree of their relationships and social connection. Frailty therefore cannot simply be a score on a chart to take account of changes in someone’s physical health.

But when I speak to practitioners and to those older persons who access health and care services, such a holistic understanding of frailty seems frustratingly absent and missing. They complain about the dominant emphasis and focus on their physical health and a limited or absent appreciation of their psychological, social and relational well-being.

From my own experience I can remember my great aunt who was an astonishing woman still writing articles and letters when she was 94. She had a fall which resulted in a hip fracture and underwent very successful surgery. Her rehabilitation focussed on her physical return to health. The stress was upon addressing her frailty. But over a short period, she declined sharply, and it wasn’t the physiological decline – as I said surgery went well and she responded astonishingly well – but it was the impact psychologically that it had upon her and her confidence which those around her recognised as the major factor in her change. Yet nobody attended to that because all they could see was the physical decline and frailty and not the change in the person.

The person who has had a hip fracture at home because of isolation and loneliness and lack of social care support and ends up going into an acute hospital for a replacement – their intensive rehabilitation back in the community isn’t – should not be – simply about enabling them to get back on their feet, to mobilise, to be able to ‘look after themselves again’. If that is all we’re doing, we’re only attending to the physiological functional dis-ease. We’re not attending to that connectedness of the person who needs to be able to maintain relationship with neighbours and with their community, and nor are we attending to their mental health needs because that certainly, in my experience of frailty and falls, is what we often forget because we’re so focused on the physiological. We know about but often fail to respond to the sheer mental distress, trauma and psychological fatigue which occurs when somebody has a major fracture whether it happens in their 60s or in their 90s.

I think we are some considerable distance from a situation where there is a robust multi-disciplinary team awareness across health and social care of the multiple factors that contribute to the decline and change in the health story of an older individual.

Another really important recent study from Coker et al makes the same point of a gap between awareness of the need for a holistic understanding of frailty and what actually happens in practice. Summarising their research study, they state:

‘There was a shared narrative among participants that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors. However, various specialities emphasised the role of specific facets of the frailty umbrella. The assessment and management of frailty was said to require a holistic approach facilitated by interdisciplinary working. Participants voiced a need for interdisciplinary training on frailty, and frailty tools that facilitate peer-learning, a shared understanding of frailty, and consistent assessment of frailty within and across specialities.’

I could not agree more about the necessity to move beyond biomedical descriptions of frailty and to support older people in a more holistic manner utilising the professional skills of all social care and health care staff.

The second issue I raised above was the suggestion that perhaps we need to move beyond frailty descriptors and to develop a more positive modelling based on how we should be enabled and assessed as ‘ageing well’

The language we use in life and in our descriptions of how we value living are critical and there can be no doubt that concepts of frailty are negative, limiting and associated with decline and deterioration. Whilst ageing does indeed for all result in change and alteration and for some that includes elements of physical or psychological change, it does not always need to be perceived in a negative and diminishing manner. Why do we see such change as negative? Is it because our societal ideal is still a concept of humanity rooted in a cult of physical prowess, our vision of humanity one of the ‘whole and able’, and that inevitably ageing, and the change that accompanies it, is seen through a negative lens?

I think the continual impugning of negative association with frailty is preventing us from being positive about ageing. If frailty impacts almost inevitably for those who age then why should we see it as decline and deficit rather than as natural and normal, to be lived through rather than avoided?

As more and more of us live for longer and longer periods of time and increasingly with healthier older age, we really need to grow up in our attitudes about age and the extent to which we either on the one hand dismiss the benefits of older age or elevate them to a false authority. Neither is entirely accurate nor helpful.

Instead, we should, I would contend, be seeking to adopt a positive view of ageing and a model of care and support, both healthcare and social care support, which is oriented not on a negative paradigm such as frailty but on the positivity of ageing. This is after all the World Health Organisation’s Decade of Positive Ageing!

Frailty is the consequence of ageing for many of us and it will happen both physically and psychologically at different stages for different people. We have to own it and see it as one of the glorious realities of us all getting old which for many of our forebears was not a possibility.

Yet in descriptions of frailty and ageing the norm is on too many occasions a limited clinical view. This is the description of ageing I came across recently – it described it as  ‘characterised by a complex and intraindividual process associated with nine major cellular and molecular hallmarks, namely, genomic instability, telomere attrition, epigenetic alterations, a loss of proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion.’ Dictionaries available online!

To age has to be seen as the flourishing of our lives, despite the challenge of the passing years. So, it is time both to broaden our vision of ageing well and to re-consider whether frailty as a concept should be replaced by ageing. Or perhaps weathering?

The late Whithorn born poet Alastair Reid sums the changes brought about by ageing in a manner that for me captures its essence – I would rather weather with the time of age than decline on a clinical frailty scale any day!

Weathering.

I am old enough now for a tree
once planted, knee high, to have grown to be
twenty times me,

and to have seen babies marry, and heroes grow deaf –
but that’s enough meaning-of-life.
It’s living through time we ought to be connoisseurs of.

From wearing a face all this time, I am made aware
of the maps faces are, of the inside wear and tear.
I take to faces that have come far.

In my father’s carved face, the bright eye
He sometimes would look out of, seeing a long way
through all the tree-rings of his history.

I am awed by how things weather: an oak mantel
in the house in Spain, fingered to a sheen,
the marks of hands leaned into the lintel,

the tokens in the drawer I sometimes touch –
a crystal lived-in on a trip, the watch
my father’s wrist wore to a thin gold sandwich.

It is an equilibrium
which breasts the cresting seasons but still stays calm
and keeps warm. It deserves a good name.

Weathering. Patina, gloss and whorl.
The trunk of the almond tree, gnarled but still fruitful.
Weathering is what I would like to do well.

Alastair Reid

from Weathering: Poems and Translations (New York: E.P. Dutton, 1978; Copyright © 1978 by Alastair Reid. All rights reserved)

https://www.scottishpoetrylibrary.org.uk/poem/weathering/

Donald Macaskill

 

This blog will next appear on the 14^th August.