Tuesday sees the celebration of International Women’s Day, 8 March, 2022. This is an annual event which raises the profile of the experience of women and girls around the globe. The theme for 2022 is “Gender equality today for a sustainable tomorrow.”  Regular readers of this blog will know that I have written often about the strong female influences in my personal and professional life, so I want to spend a bit of time this week reflecting on some connected thoughts from those insights.

1.

It was as far back as 2017 that I appeared before the Scottish Parliament’s Economy, Jobs and Fair Work Committee and gave evidence relating to the Gender Pay Gap in Scotland. A few months later the Committee issued its thorough report ‘No Small Change’  which identified that gender segregation was a real phenomenon within the care sector in Scotland. Indeed, Scottish Care in its evidence to the Committee argued that there existed systemic gender discrimination in the way in which we treated the predominantly female social care workforce in Scotland. Sadly, some four or five years later despite all the rhetoric about reform and reconceptualising care services we are still faced with clear gender discrimination in the way in which we prioritise social care and its largely female workforce. I am more and more convinced that we will not address the dis-ease afflicting social care provision unless we call out the gender discrimination which is so characteristic of the way in which social care in general and its workforce in specific are treated sector. At the risk of personal repetition, I said five years ago that were this a workforce which was 86% male and not 86& female then we would not have had the travails of unequal pay nor the ludicrous terms and conditions which are deemed acceptable by contracts from local authorities. Indeed that latter point was forcefully and cogently articulated in the Fair Work in Scotland’s Social Care Sector Report in 2019. It stated:

‘The evidence suggests that the undervaluing of care work is, to a significant extent, linked to the predominance of women workers in the sector. 11 The view of the Social Care Working Group was that part of the failure to value social care comprehensively is due to its status as women’s work. Women face systematic labour market disadvantage, including occupational segregation, workplace discrimination and lack of flexible working. Institutionalised undervaluation is common in highly feminised jobs and occupations, contributing to the gender pay gap (of 15% in Scotland). Social care work is also less visible than other work, taking place in service user’s homes rather than workplaces, with implications for skills recognition and for collective organising.’ (page 14)

Calling out gender discrimination in social care requires us to continually underline the reality that gender segregation is a fact which requires attention. Part of the reason we fail to value social care as a whole is that it is still seen by and large as ‘woman’s work.’

2.

At the heart this gender segregation challenges our understanding of what care itself is and the value that we put on the art of care. In the last few years, we have seen the offensive articulation of a belief that care is ‘low skilled’ and I cannot help but believe that such an assessment is in part because of both the fact it is undertaken predominantly by women but also that care itself is deemed to be of lesser value and import to society than a technical set of skills or attributes. Such pervasive gender stereotyping must be challenged not just for what it says about the workforce but just as importantly for what it conveys about social care.

It will come as no surprise that for me social care and our ability to prioritise it and value is both the bedrock and heart of our society and should be valued because it evidences a priority which captures the essence of who we are as a society and as communities. But clearly despite the fact that social care is a massive economic contributor to the overall economy wider society still perceives it in negative terms, in language of cost, burden and deficit. Take for instance the much heralded launched of the Scottish Government’s National Strategy for Economic Transformation report ‘Delivering Economic Prosperity’ in the last week. Except for mentions of support for the Living Wage in Adult Social Care and a passing reference to technology in care, social care doesn’t merit a mention.  I am utterly dismayed that despite the travails of the last two years and the heightened awareness of the intrinsic and fundamental importance of social care that this document fails to prioritise social care and its workforce, businesses, and employers. Instead of a nation considering that part and parcel of economic prosperity is a prioritisation of a social care system and supports that potentially becomes the engine of that prosperity there is a complete failure to think radically and creatively with people at the heart. Gender bias and the pay gap are mentioned as is the need for radical childcare, but the contribution, entrepreneurship and creative potential of the largest female workforce (outside of the health sector) is ignored.

3.

But the systemic gender discrimination we witness isn’t just to be found in the way we treat our social care workforce, or fail to recognise its economic value and ingenuity, it has also been sadly the experience of our response to the global threat which has bene the pandemic.

As the United Nations in various reports in 2020 and 2021 has underlined the pandemic has highlighted the way in which as modern societies, we are so reliant upon women both in the frontline of care and health services but also at home.

But as the United Nations Women report on Covid19 states:

‘In times of crisis, when resources are strained and institutional capacity is limited, women and girls face disproportionate impacts with far reaching consequences that are only further amplified in contexts of fragility, conflict, and emergencies…

Despite these numbers [in health and care], women are often not reflected in national or global decision-making on the response to COVID-19. Further, women are still paid much less than their male counterparts and hold fewer leadership positions in the health sector. Masks and other protective equipment designed and sized for men leave women at greater risk of exposure. The needs of women frontline workers must be prioritized: This means ensuring that health care workers and caregivers have access to women-friendly personal protective equipment and menstrual hygiene products and are afforded flexible working arrangements to balance the burden of care.’

4.

Lastly any consideration of International Women’s Day and a reflection on social care has to also face the challenges posed by the unequal treatment of women in terms of their health and social care. It is not just the social care workforce which is predominantly female and the victim of gender discrimination it is also sadly the fact that the majority of those supported and cared for are also themselves women. It is estimated that in the United Kingdom that 61% of people with dementia are women and 39% are men. Accepting that this is in part because women live longer than men it is not that difficult to evidence discrimination behind the data. There is relatively little research focus on the specific genderised characteristics of the disease that may impact upon women. Indeed an earlier report by the Alzheimer’s Society rightly stated that women and dementia are the ‘marginalised majority.’ The fact that dementia is the major cause of death of women across the United Kingdom is a reality that few consider or talk about. I cannot be the only person who having marvelled at the unified scientific community which brought about such astonishing breakthroughs in the discovery of the Covid19 vaccine, has pondered what would happen if equal focus and priority was given to finding treatments and interventions for dementia. Is it too simple a leap to suggest that both age and gender discrimination has a contribution to such relative lack of fiscal priority?

International Women’s Day is an opportunity for us all to focus on the contribution and creativity of women in our communities; it should also be a call to address the systemic discrimination that treats women and girls less favourably and equally, whether in social care, economic opportunity or in disease management and research.

Donald Macaskill

I’ve often remarked in this blog that in the strange patterning of days some words seem to become prominent in the conversations of the moment. Perhaps the word of the past week and for such strange times is ‘freedom’.

Freedom, that most elusive of desires, an emotion and state unable to be grasped and held, always open to escape, always unsettling, rarely achieved. It carries with it connotations of being empowered, having the right to act, to speak, or think as one wants. We celebrate freedom of choice, the liberty to be autonomous, the right and privilege to not be shackled or imprisoned by another or indeed by ourselves. In literature and art we try to depict the freedom of birds that fly, of oceans that stretch out, of rivers that determine direction. Freedom so hard to describe but so precious when absent.

Our newspapers across the political and tabloid/broadsheet spectrum were trumpeting headlines this last week declaring ‘Freedom Day’ a day when restrictions will be removed or largely limited. All of this following the announcement by the First Minister that on March 21st, the mandatory wearing of face masks in all public places, including pubs, restaurants, and shops along with the one metre physical distancing rule and the legal requirement for businesses to keep customer contact details will be removed. She declared this “is possible only because widespread vaccination coverage and better treatments have reduced the direct harms of the virus.”

Whether or not the slow restoration of former practice can be defined as freedom is a moot point. Indeed, along with the removal of restrictions comes the advocacy for caution and concern, a call to take public and personal responsibility. This is to be manifested in individuals choosing voluntarily to wear masks in crowded or public places, to be ‘sensitive’ to those who may have particular risks and vulnerabilities, and to act responsibly should one become ill.  A call to good neighbourliness and social responsibility is to take the place of mandating, legislation and requirement.

For many fellow citizens the reverting to former practice will indeed feel like a sense of freedom, but for not a few the next few weeks and months remain uncertain and fearful and feel like the lessening or loss of freedom. The disability advocate Dr Sally Witcher (@SalWitcher) writing on Twitter this past week asks:

“ Why should we have [to] be at the mercy of other people’s selflessness & willingness to protect/look after us? We’re not objects of charity. We’re equal active citizens. We fought for years for equality & human rights as relying on people to do the right thing just doesn’t work.

Of course we all want to go back to ‘normal’. None more than me after 2 years indoors. That’s what I call a massive restriction! Compared to that wearing a mask, etc is no restriction at all. And if businesses installed air filtration there have to be business benefits.

So-called ‘restrictions’ are protections that enable everyone’s freedom, not freedom for some at the cost of loss of it for others. They keep everyone safe from long Covid, new variants, and still unknown long term clinical consequences of even mild illness.”

It certainly, does not feel like freedom for so many people who have needed the maximum degree of self-protection from this still pernicious and dangerous virus.

What will happen to social care staff in care homes and homecare remains at the time of writing at best uncertain. Take care homes as an example. We are still awaiting guidance from clinicians and Public Health Scotland as to what, if any mitigations and measures will be required into the future. It is likely there will be a degree of testing for staff and potentially visitors. But how this will be undertaken, by whom, and how it will be paid for given the UK Government’s statements to remove free access to tests (including in care homes) in the last week, seems uncertain.  What will be required about masks if anything?

But what is even more pressing is the need for clarity on the current restrictions being placed on care homes. We are still caught in the endless cycle of care home residents having to isolate should an outbreak be declared in a care home and many unable to engage in normal activity and relationships. Such periods of isolation can literally go on for weeks because no sooner does one period of 14 days end then another often seems to start creating a new ‘outbreak’ and often as a response to very few cases. As many of us have been arguing with and trying to convince clinical leaders – and to date unsuccessfully – such extended periods of isolation (even with a named visitor in place) are unacceptable, disproportionate, unnecessary, and hugely damaging.

When is freedom going to come for them and what will it look like? In a week which has seen a significant increase in the number of Covid cases affecting care home residents this virus shows no signs of going away. So what does living with the virus mean for these individuals – a perpetual state of isolation and confinement? What quality of life is that? Anecdotally many managers and staff are saying to me that the level of decline and deterioration of residents forced into such isolation is wholly unacceptable and is they are convinced a set of actions which shortens life and certainly precipitates significant cognitive decline. This is simply not justifiable on any grounds, epidemiological, clinical or moral, nor is it, in my opinion, at all proportionate or legitimate in a legal sense. We have declared freedom for the wider public and yet still have no open door to a better future for those who have suffered the most.

Sounds of freedom outside and the rush to throw off masks and restrictions for so many in our care homes ring hollow and empty in both rhetoric and reality.

But of course, freedom took and has taken on a wholly different level of meaning in the last few days as we have seen the horrific scenes from the Ukraine and the results of a despotic dictator wreak havoc across a modern, inclusive and open society. The fragility of civilisation has never been so vivid as I have watched fathers break down in tears leaving their children behind as they are conscripted into a fight against the enemy of their people; as I watched people cowering to shelter from attacks in underground stations; as bombs were seen to rip open the homes of the innocent and land on kindergartens; as tens of thousands started a journey as refugees seeking a border of peace and escape. As Europe is plunged into a darkness we have not seen for generations, we are all of us yearning for a return to peace. Freedom seems so far away for so many in the blood and tears of the Ukraine this morning.

All of us wherever we are and whoever we are seek that common gift of freedom knowing only too well that sometimes it comes at a very real price. So today with so many I will spend time thinking of the women, men and children of the Ukraine before all else because it is only in solidarity with those who are suffering that true freedom for ourself comes.

I leave you with the words of a poem:

freedom

the elusive one;

once caught always lost,

once lost always found,

where is she to be searched for?

when does she discover you?

 

they look for her in their books

and search for her in their stratagems;

by policy papers and wordy manifestos

they fail to imprison her laughter.

 

they seek her in empty corridors

echoing with the sounds of powerless dictators,

dined to bloating on their own importance

fed to obesity by a diet of propaganda.

 

they seek her in the warmth of missiles

and search for her amongst a bed of nuclear pillows

pulling back the blanket of macho security

to reveal the nakedness of fear.

 

they seek her in the words of hatred

where prejudice becomes the scapegoat’s friend

and bullying the national sport

of nations too ashamed of difference.

 

they seek her in your heart

where she lies dormant

emptied of enthusiasm,

lazy through lack of exercise

exhausted by inactivity.

 

freedom

the elusive one;

when will they learn

she is not a place but a sound

not a word but a whisper

not a weapon but a heart

not a prize but a gift.

 

When will they learn?

when freedom imprisons hate

and freezes out fear.

 

Donald Macaskill

Behind every policy and legislation there is often a passion and a movement; behind every change there is frequently a vision and an aspiration. The world of social care and social work in Scotland is no less than any other sector. We have plenty of aspiration and hope, expectation and possibility.

The creators of the seminal and ground-breaking Social Work Scotland (1968) Act were inspired by the realities of deprivation, harm and failure evidenced in the 1950s and 60s across a Scotland impoverished by the trauma of war and the failed priorities of consecutive Westminster administrations.

The disability civil rights movements of the 1960s through to the 1980s declared that all people regardless of disability had equal rights to belong, to be included, to be heard and to be valued. They inspired and influenced policies such as ‘The Same As You?’ (2000) which led many of us to be involved in the closure of our long stay hospitals. And with an adequately resourced Change Fund it enabled a process of people with disabilities beginning to be included in their communities not shut away from belonging; it gave voice to people so that they could articulate their story and their hope; it rooted in practice and policy a change in orientation which recognised that it was mainstream society that disabled individual contribution rather than the labels and conditions by which we imprisoned individuals in asylums.

The desire to have control and choice, to be able to take charge of your own social care support and care, to be freed from the presumption that the Nanny State knows best and delivers best, to be able to become the director of your own decisions, all  under the umbrella of the independent living movement was that which provided the energy and spark which brought about perhaps one of the most dramatic changes in social care legislation and policy in the form of the Social Care (Self-directed Support) Act in 2013. Being present at the Ministerial launch I recall the passion and hope, aspiration and creative possibilities of designing a better tomorrow from the recognition that things were broken.

So too the creation of what became known as a health and social care ‘integration’ policy enshrined in the somewhat dry and limiting Public Bodies (Joint Working) legislation in 2014 – was centred around the aspiration that there would be one continuous pathway from first point of contact with social work all the way through support and care whether in hospital, community or care home, all the way to the end of an individual’s life. The dream and vision was that a person should not have to tell their story to multiple people, should not have to undergo multiple assessments which detailed and described the same thing because data was not transferred, professionals did not communicate and systems did not speak. Integration was primarily and always motivated by a vision of the person, the citizen, at the centre having control and agency.

Then most recently we have had the huge amount of commitment and shared vision and desire which made the Independent Review of Adult Social Care – also known as the Feeley Report – into a document whose words came off the page and painted a picture of possibility for the future of social care delivery in Scotland. It is a document which attempted to live up to the vision of a new beginning rooted in the at times painful experience of the pandemic and before. It was a vision of human rights and choice, of person-led agency and support, of contracts and commissioning of services which were equitable and fair, of reward and recognition of care as a career of potential – and so much more. It was less concerned with the structure more interested in the soul, less about the model more focussed on the energy.

The landscape of social work and social care in Scotland is indeed rich in movements of change and in voices of challenge. There is enough in text and legislation to motivate and inspire. The problem has always been implementation – the challenge and the failures have always been our ability to drain the vision from the text, to limit the possibility which progressive legislation offers. The sin has been to be tempted to make the system and the model, the vested interests of power and traditional practice, the familiarity of the known and the predictable – into the gods of the moment.

Our ‘implementation gap’ as Feeley termed it, has been the pit down which many an initiative, so much creativity, and so many hopes and aspirations have fallen. It is a deep hole but not an accidental one and it can be filled in!

This last week in so many conversations I have heard voices of fear and anxiety being raised about what the future of social care supports and social work might look like in Scotland. I share those very genuine fears and concerns but knowing and naming them, calling them out and recognising the risks, is part of the way in which we can avoid failing to live up to the aspirations which so many have articulated and so many hold.

The most obvious fear and this is well represented in much of the feedback and analysis in the consultation to the National Care Service is that we become so obsessed with the structures and systems, with the models and processes, with the titles and power-bases of a creating a massive new system that we lose sight of the vision and the energy which is necessary to ground real change into felt reality.

The First Minister has on a number of occasions articulated her desire to bring from the hurt of the pandemic a change which will be worthy of that pain – the creation of a National Care Service. A noble aspiration but one which has risks of falling into that implementation hole well before the summit of promise is reached.

One of those risks, I believe, is that the energy that directs success has to be fed by a proper awareness of what social care is and is not. Social care is not health care – we certainly do not want a shadow of the National Health System – and any attempt to achieve that would be a crippling failure and a massive denial of the hopes of those who use, work and deliver social care services and supports. We have all of us to be aware of and defensive against the creeping medicalisation and clinicalisation of social care and social work delivery. Such is an anathema to individual choice, citizen control, personal agency and an approach which is about enabling participation not fostering dependency, nurturing citizenship not limiting contribution. Social care can never be the maidservant of a National Health Service. What we want are the principles of choice and individual control, of independence and real engagement and involvement, of participation and personal control to be at the heart of what grows out of the next few years.

The danger is that legislation can either strangle aspiration or even if well formed can falter at the point of implementation. Integration became a bun fight between two goliaths – the NHS and local authorities – with Health and Social Care Partnerships the emasculated body in the middle and with Chief Officers engaged in a constant referee match between vested fiscal interests and power dynamics. As someone who examined why integration did not work – a lot of the time – the system failed the people by failing to make hard decisions when they were needed and failing to bring order to chaos when it occurred. Instead of the dream of integration with the person at the centre of a continuous pathway of consistent support and care – we have shamefully disappointed the dream.

Even if we get the legislation right – as we certainly did in the Self-directed Support Act – again the gap of implementation where fiscal limits and austerity, where power bases in senior management at local level, led to an inevitable suffocating of promise and a marginalising of creativity. Even today I hear the ridiculous scenario where people talk about SDS on the one hand and social care assessment and provision on the other – there is and should only be one way of accessing social care and that is through self-directed support. There is no excuse – and for my area of interest especially for older people – of citizens being denied the choice, budgetary control, individual say over which provider you want – in any place in Scotland today. Yet the reality is that in so many places choice is based on what age you are, who you know, what party colour the local authority political leadership is, and how much of a battle the local HSCP has managed to wage against the Big Two. We have shamefully disappointed the dream.

The next few weeks and months will be critical for the formation of the National Care Service and the much wider hopes and dreams of the Feeley Review. The concerns and fears I am hearing are that we will focus so much on structure and process that we lose the passion and purpose. We will be so concerned on achieving the model that we will lose sight of the necessity to really involve and include, engage and engender the energy of the people who need to make that journey with us. There is a real fear that the necessary leadership with real world knowledge rather than acquired  awareness to achieve this change is simply not there either politically or operationally. Such leadership demands inclusivity and involvement, not partisanship and a failure to engage. There are too many whispers and behind the door conversations. Indeed, this is perhaps especially the case in the bringing together of health and social care – especially the providers of the latter – a reality that in the last calendar year has barely happened at all. Meaningful change is never achieved by siloed management.

There has always been an energy and movement in social care across Scotland. It is one at its best that has mirrored our humanity and hospitable concern for the other, to include and involve all, to be open to the challenge of the new and the creativity of the different. It is a social care world which has rooted equality and fairness, human rights and dignity at the heart of all that is delivered. It is also one which has authentically talked the talk and been real rather than fictional whether that be about fiscal reality or delivery challenge.

We are about to start a whole series of political debates on the creation of a National Care Service – in these I hope our leaders will listen, not to the rhetoric of political echo chambers, but to the people who use social care supports, the workers who deliver them, and the providers and employers who are the organisations by whose agency most social care support is enabled.

When all is said and done change is born out of a vision of betterment and of new possibility, of a new and better way of being and belonging, of caring and compassion. The current Poet Laureate Simon Armitage in his poem ‘A Vision’ warns of the possibilities of our visions landing in the landfill site of disappointment. But the way we prevent the architectural dreams of a changed world becoming the missed opportunity of our future, is to work hard; to involve all; to listen deeply; to learn openly and to create together rather than apart. The future of social care deserves no less.

 

A Vision

by Simon Armitage

The future was a beautiful place, once.

Remember the full-blown balsa-wood town

on public display in the Civic Hall.

The ring-bound sketches, artists’ impressions,

 

blueprints of smoked glass and tubular steel,

board-game suburbs, modes of transportation

like fairground rides or executive toys.

Cities like dreams, cantilevered by light.

 

And people like us at the bottle-bank

next to the cycle-path, or dog-walking

over tended strips of fuzzy-felt grass,

or model drivers, motoring home in

 

electric cars, or after the late show –

strolling the boulevard. They were the plans,

all underwritten in the neat left-hand

of architects – a true, legible script.

 

I pulled that future out of the north wind

at the landfill site, stamped with today’s date,

riding the air with other such futures,

all unlived in and now fully extinct.

 

From:  Tyrannosaurus Rex Versus The Corduroy Kid

Copyright ©:  Simon Armitage

A Vision poem – Simon Armitage poems | Best Poems (best-poems.net)

 

Donald Macaskill

 

 

 

 

At the current time the UK Government is undertaking a consultation on major proposals to change the provisions of the UK Human Rights Act – a piece of legislation which covers Scotland. The proposed changes are being presented as insignificant, but the reality is the complete opposite, and they should be a matter of concern to anyone concerned with the protection of rights in Scotland.

In his preface to the changes the current Justice Secretary, Dominic Rabb, asserts in passing that there are no plans to depart from the European Convention of Human Rights (ECHR) but he then states:

‘…our system must strike the proper balance of rights and responsibilities, individual liberty and the public interest, rigorous judicial interpretation, and respect for the authority of elected law-makers…

We make far-reaching proposals for reform, with a particular focus on those quintessentially UK rights, such as freedom of speech and the right to trial by jury.’

All sounding innocent enough and a blatant appeal to a perspective where the essential ‘values’ can be enshrined in a defence of freedom of speech even if the understanding of what that freedom is is frequently absent.

Throughout the narrative of the consultation plays to the crowd and a sceptic if not hostile audience and attempts to dress significant change in the clothes of acceptability.

It states later an aim to:

‘… overhaul the Human Rights Act passed by the then Labour government in 1998 and restore common sense to the application of human rights in the UK.

…The Bill of Rights will protect essential rights, like the right to a fair trial and the right to life, which are a fundamental part of a modern democratic society. But we will reverse the mission creep that has meant human rights law being used for more and more purposes, and often with little regard for the rights of wider society.

I will leave it to commentators far more qualified in the law to describe the detail of the proposals and why they are so concerning. Indeed, in that regard I would strongly recommend you look at the work of the British Institute of Human Rights and their campaign to defend the Act.

I want to, however, reflect on why in 1998 the Human Rights Act was one of the first pieces of the new Labour Government.

Anyone around in the 1980s and 1990s, as I was, would be well aware that if you believed for whatever reason that your human rights were being diminished or broken, abused or removed that the recourse you had open to you was to take a case all the way to Europe. From the women who fought for protection during pregnancy and won statutory support of their employment to the young people who fought to outlaw corporal punishment in our schools – Europe was the seat and source of protection and legal justice. It was a destination both distant and costly – a justice hard won over many long delays and years.

The creation of the Human Rights Act was under the banner ‘Bringing Rights Home.’ That phrase said it all – its essential core purpose was not to change or add to the human rights which were the fruit of the sacrifice of our forebears and which found voice in the UN Convention or the European Convention. No, the gift of the Human Rights Act was to bring those rights close to each of us. The Act made it possible for every citizen who felt the need for protection of their rights to have recourse not to a distant European court but to local courts. It sought to bring justice to your doorstep.

The Human Rights Act was about making human rights meaningful and relevant to every citizen. If you felt aggrieved, you had the potential to fight your case in your own community.

But even more important the Human Rights Act was about changing the way we talked about and used human rights. It was about taking these principles out of the courtroom and making them the conversation of community and relationship. The HRA was about making human rights mean something for the education you receive, the care you were given, the decisions made by your government – it was all about making human to go to relevant and real.

Over the years contrary to what some newspapers and some parts of the media might wish to portray human rights cases were to do with defending people with disabilities or making sure of equal treatment regardless of gender in terms of pensions – much less than prisoners, or foreign terrorists – they were about the issues of living together in modern community.

Now in truth there have been times when they have not achieved what they might have. There have been moments when we have paid lip service to our human rights laws- perhaps most poignantly during the pandemic. That is not the fault of the law but of those who have failed to live up to the higher aspiration and morality that human rights laws hold before ys.

The politicised attempt to diminish our human rights affects everyone for whom access to justice impacts on the care they receive or the life they would live. It impacts on decisions about treatment and medicine, around health and housing, about justice and the environment.

I hope we can all find the voice to keep human rights close to home. We dare not allow others with proposals ostensibly limited to allow the eviction of our human rights from our homes. It’s time to make sure we keep human rights at the centre of our homes. The Human Rights Act is the closest thing I know that makes sense of and roots the promise of the famous words of Eleanor Roosevelt from 1958:

‘Where, after all, do universal human rights begin? In small places, close to home—so close and so small that they cannot be seen on any maps of the world. Yet they are the world of the individual person; the neighborhood he lives in; the school or college he attends; the factory, farm, or office where he works. Such are the places where every man, woman, and child seeks equal justice, equal opportunity, equal dignity without discrimination. Unless these rights have meaning there, they have little meaning anywhere.’

Donald Macaskill

See also https://www.bihr.org.uk/blog/why-the-human-rights-act-matters-to-me-donald

At times during this pandemic a word, phrase or concept just seems to appear from nowhere to occupy a position of dominance in debate and discourse. This last week everywhere I looked I have seen the word ‘trust’ or heard it mentioned on radio or television, in meeting or exchange.

Trust is a fundamental characteristic of our being with one another in so many dimensions of our living. It is a word rich in meaning and possibility. The dictionary describes it as a ‘firm belief in the reliability, truth, or ability of someone or something.’ It denotes a sense of confidence, belief, and faith. All of these are concepts which are inter-related and inter-changeable. In my blog this week I want to consider the various dimensions of trust as they have struck me this past week and how fundamental a moral ethic of trust is especially during pandemic times.

Political trust.

In the job I do at Scottish Care representing a wide range of members with diverse perspectives I have always sought to refrain from direct comment on the merits or otherwise of any political party either in Scotland or in the United Kingdom but have hopefully been consistent in a critique of policies, behaviours and practices which have acted against the best interests of the care sector and those who receive care and support especially older individuals. Let’s face it there is not exactly a shortage of areas of social care failure across the UK on which there has been the requirement for critique!

When there is a time of crisis and challenge like all individual citizens, I have looked to political leadership to make decisions and act in a manner which upholds the best interests of the whole population, especially those who might not be able to advocate for themselves. Confidence and trust in political leadership during the pandemic has been essential, and whilst there have been areas where it has been necessary to be critical and to highlight shortcomings, what has remained as a strong expectation is that sense of trusting political decision-makers – however hard the decisions might have been – as having the best motives, intentions and aims. As we continue to take measures which reduce restrictions and mitigations to protect public health the extent to which we trust our political leadership has become if anything even more important, especially as the spirit of consensus and mutual agreement has diminished.

The events of the past few weeks at Westminster, the language of scurrilous accusation and demeaning diatribe, the occurrences of behaviours inconsistent with a required morality and social ethic, have diminished all those involved and have brought so much that we value in our political system into the most profound disrepute and deepest disrespect. We cannot move forward as a society to face the challenges of the future with a deteriorating political trust. We must be able to have confidence that the interests of the population are advanced ahead of the partisan self-interest of a few. Just as we trust that the bank notes in our pocket will be redeemed for their true value, we require a trust in political leadership which lives up to the highest values of public service and ethical practice.

Pandemic trust.

We have spent a lot of time in the last 23 months becoming amateur experts in epidemiology and the science of infection and pandemics. There has been no shortage of scientific commentary and some of it has been conflicting and contradictory. Some have been unable to deal with the fluctuating stances of scientific opinion believing that science provides clarity in definitive black and white colours. If anything, the pandemic experience has taught us that ‘trusting the science’ or ‘being led by the science’ is not a simple act of reading then implementation bur rather is one of analysis and interpretation. Trusting the science has been critical at various stages of the pandemic and there have been diverse responses to the same data because the nature of analysis is that there will always be degrees of interpretation and subjective opinion. But regardless of nuance and divergence, I do believe that as a whole we have both at an individual and collective level elevated the role of scientific analysis to a position of critical importance. But this has not come easily and the challenges of the next few months and weeks as we come out of Omicron will test the degree of trust perhaps beyond breaking point.

For those of us who are not able to scientifically verify the truth of statements and assertions made by ‘experts’ we have to ‘trust’, to be confident in the motivation and skill, the assertion and articulation of those who have been appointed to give advice and influence decision-making. That is not always a comfortable experience and perhaps gets to the heart of the nature of trust. Trust is always relational, it is the human letting go of self-defence, it involves the risk of encounter and exchange which might threaten and reassure in equal measure. Think of any meaningful human relationship you have ever had and at some point you enter into a landscape of trust and belief, when you lay down what you ‘know’ and can ‘verify’ and have to develop the hope and positivity which confidence in another over whom you have no control, begins to develop and grow. The cost of loving another is trusting beyond knowledge and living in hope and assurance.

Partnership trust.

Trust also has to do not only with individual person to person relationships but with the encounters we have with organisations and individuals who we work alongside and relate to. In the workplace trust is fundamental to the achieving of shared outcomes and aims. But as anyone who has ever worked on any shared ventures knows only too well, the reality of trust is something which has to be worked at and strived for – it does not just happen. Telling someone to trust you and to agree with your position or stance has to be grounded in the reasonableness of their prior-knowledge of you and the conviction that you have their best interests at heart.

The worlds of social care and health have not always ‘trusted’ one another – not that they have enmity or disregard for one another – but rather their mutual knowledge and awareness of the other has been limited or at times absent. Integration of health and social care services was meant to change all that. We were all meant to be developing systems and processes which had the person receiving care and support at the centre, and indeed in the lead as the director of their lives. We have fallen well short of that aspiration as the ground-breaking Independent Review of Adult Social Care Report indicated when it was published a year ago on Thursday last. The Feeley Report as it became known was received with the warmest and most extensive of welcomes by disparate parties – partly because through its author Derek Feeley – bonds of trust had been developed that suggested that its words were authentically the aspirations and hopes, dreams and vision of those who use social care supports and that it offered the promise of a reformed social care system for adults in Scotland.

This past week has also seen the publication of the responses to the Scottish Government’s consultation on the envisaged National Care Service which was a key part of the Feeley Report. There are many of them but having read quite a few they also share a sense that the time is right for change and that this is a once in a generation opportunity to achieve that. But there is also a sense that we must not in our focus on processes and structures, on systems and models, lose the vision and energy of the Feeley Review. This is where the trust comes in – those of us who for years have campaigned for a change to the delivery of adult social care which creates care support models sensitive to the people who use them, appreciative and valuing of the frontline workforce, realistic in the required resource and costs involved, and yet dynamic in inclusive flexibility – we have put our trust in our political leadership to bring these dreams to birth. We are trusting our political leadership to overcome partisanship, both at local and national level, and do what needs to be done to deliver a sustainable social care system that works for all citizens and treats all with equality, fairness and dignity.

Trust – whether political, for a period like a pandemic, or as the energy of partnership in change and reform – is the most essential of ethical values and commodities. Its marks are the ability to include and involve all, to hear the voices that disturb and unsettle, to soothe the concerned and fearful, to be consistent in compassion and courage. We all of us deserve to live as citizens in a land of trust.

This last week I was honoured to hear a reflection by the distinguished American social care leader Stuart Kaplan. In it he said that in a world of such uncertainty we can all have to be true and sure to our word. ‘Trust is our essential currency.’

And in relationships built on trust we can find hope and restoration, renewal and reform. The contemporary American poet Thomas R Smith puts it well:

Trust

It’s like so many other things in life

to which you must say no or yes.

So you take your car to the new mechanic.

Sometimes the best thing to do is trust.

 

The package left with the disreputable-looking

clerk, the check gulped by the night deposit,

the envelope passed by dozens of strangers—

all show up at their intended destinations.

 

The theft that could have happened doesn’t.

Wind finally gets where it was going

through the snowy trees, and the river, even

when frozen, arrives at the right place.

 

And sometimes you sense how faithfully your life

is delivered, even though you can’t read the address.

 

Poem copyright © 2003 by Thomas R. Smith from Trust by Thomas R. Smith | Poetry Foundation

Donald Macaskill

 

One of the first tasks I undertook when I started in my role as CEO of Scottish Care nearly 6 years ago was to go around the country and take part in a research project which involved me interviewing a number of frontline nurses in care homes. It was an amazing, humbling, and inspiring experience. Along with colleagues what came out of those conversations was developed into a report called ‘Voices from the Nursing Frontline.’ It told the first-hand experience and stories of nurses who had chosen to work in social care and care homes in particular. It was raw and honest, but also celebratory in valuing the exceptional importance and distinctiveness of care home nursing.

I have re-read the report and the words of these nurses in the last few days, sparked off in part by the publication of a survey from the Royal College of Nursing in Scotland, but also by comments from nursing colleagues in the sector. The RCN survey indicated that as many as 60% of nurses are actively considering leaving the profession. In what follows I want to share some thoughts on the current status of care home nursing in Scotland and why I believe it to be in very real crisis and in need of specific and targeted attention.

The Voices report articulated the breadth and extent of the role which care home nurses undertook. If I had not known before, I certainly knew after these conversations that the job entails an astonishing array of skills and requires real depth of expertise and knowledge.

Nurses in care homes are often the only nurse on a shift and as such a great deal is placed on their shoulders not least as the acuity and clinical needs of residents has risen so sharply in the last few years. They are frequently individuals who occupy leadership roles in our care homes whether as senior staff or often as managers responsible for the smooth running of the home not just exercising a clinical oversight role. Added to this they are the effective leaders of and support for social care staff. These are highly skilled professional leaders dealing with a whole range of clinical needs in residents including dementia, neurological conditions, delirium, palliative and end of life care, pharmaceutical interventions, frailty, rehabilitation, late-stage cancers and so much more. The care home nurse is a specialist in a considerable number of areas and not a generalist. They do so much often without the peer support that is available in an acute setting.

After being involved in the Voices report, along with others, I argued that both nursing regulatory bodies and nursing academic schools needed to create and value social care nursing as a distinct specialism in the same way as is done for paediatric, learning disability or mental health nursing. I hope one day that will be undertaken in earnest because in a very real sense all nurses need to develop the skills a care home nurse is required to evidence and display.

Yet having just noted the advanced clinical and social care skills required I cannot but reflect on an undercurrent in the Voices report which has become not only more pronounced but has grown in recent times in Scotland. That is the issue of value, respect and professional regard. One nurse stated in 2016 that:

“In hospitals, nursing homes were considered second class establishments. Our skills are undermined by the NHS due to us not using IV drips! The complex nature of communicating with those with dementia is not recognised.”

I well remember a nurse saying to me that her NHS colleagues thought she would become de-skilled, was taking an easy route out and that the care home sector was a dead end for anyone interested in career progression. She told me that the disdain from her former acute sector colleagues was palpable, as someone told her, ”It’s not real nursing is it?”

Now you might say that any one person’s experience is not always reflective of the whole. That is undoubtedly true were it not for the fact that for the last few years and especially in this last year I have continually heard from frontline care home nurses their growing dismay at their sense that others in the health and care system disrespected their professionalism, expertise and skill base.

Over the last few days there has been a lively social media debate about care home nursing, and you cannot read some of the comments and not conclude that these women and men have been made to feel less valued, de-skilled and dis-respected even more than other nursing colleagues in other services.

One experienced nurse stated:

@andreawyllie : When I first started out on my nursing journey, older people & mental health nursing were considered “Cinderella” services. CH nursing wasn’t even included in that category. Not much has changed in attitudes in 25yrs. It’s not just the nursing it’s how we as a society value people

Others commented:

@Justacarehomeg1 : The impact on social care staff at all levels has been largely ignored. Working front line with covid, with restrictions which cause moral dilemmas to staff day in and day out.

@andreawyllie: Just discussing this very thing with this morning and what the lasting impact may be for social care as we add in the lack of respect and value given to social care staff and the blame culture that has also had to be managed through the pandemic

@YvonneSManson : All these new NHS based oversight groups that got set up only further compound that stigma of NHS is better. Imagine setting up teams to oversee, make decisions on care homes with people who didn’t work, live or visit care homes can you imagine that happening the other way around!

I would encourage you to read the debate because it is inescapably blunt in its analysis that we are failing care home and social care nursing in Scotland.

The pandemic has been crippling and hard for frontline care staff, nurses perhaps especially so because of their leadership roles. Many have shared with me a sense of abandonment, the stress and emotion of dealing with loss and death, the fear of whether they would carry the virus into the care home or back to their own homes; the constant struggle to balance the need for restrictions with their desire to help residents enjoy their life; the continual requirement to be strong for colleagues; to be always up to date with the avalanche of new Guidance arriving just at the point of exhaustion; the disproportionate scrutiny from those who know not what they were talking about; the demands of reduced staffing; and their own inner questions about the level of care possible in situations such as forced isolation and separation from families with which so many disagreed.

Many have shared their real pain at the constant barrage of criticism and blame directed at care home nurses and managers not least from sections of our political and media worlds. And add to this, and uniquely in Scotland, the nature of constant investigation from Operation Koper where every single Covid death up to this day is investigated in care homes, thus putting immense pressure and stress on nurse leaders – a process consciously and subconsciously constantly demanding they ‘prove’ they did not make any errors or at least one which instils fear, guilt and anxiety. They have felt as if they were fighting a battle against a virus with one hand tied behind their back. Can you even begin to contemplate the outcry if this process of continual investigation and scrutiny and limiting of professional integrity was happening to nursing staff in an NHS ward?

The specific and personal observations quoted above and there are a lot more on Twitter and other social media are also clearly evident in the report on oversight and inspection published by Scottish Care two months ago and around which thankfully there has commenced some shared work to address the issues highlighted. That report stated quite clearly that we were seriously getting things wrong in the way we are allegedly supporting the care home, and specifically, the nursing care home sector.

I would contend that the comments expressed online this week and in the report are not accidental but rather are reflective of a damaging failure at senior health leadership level in Scotland both politically and operationally to value the professional integrity of and to seek to appreciate the role specialism of care home nurses most especially during the pandemic. Interventions might have been ‘well-intentioned’ and designed to ‘support’ but they have backfired and only served to compounded the problem and sense of disrespect, not least because of the lack of real engagement with, involvement of, and partnership with care home nursing professionals and the sector. No other professional group I know in social care or medicine would tolerate what is now happening in care home nursing.

The RCN report stated baldly the risk of us haemorrhaging real talent from the nursing profession in the NHS – I would go as far as to say that that worrying analysis can be multiplied ten-fold when one considers the social care nursing workforce. There is an urgent need for attention and action, but that must start with the development of trust and respect for the individuals who work as care home nurses. That respect seems singularly absent.

The Voices report some 6 years ago made 12 recommendations. It is an indictment on all of us involved in health and social care leadership that each and every single one of them remain unaddressed in large part to this day. We have not progressed matters with any positivity, rather in the last 22 months we have made matters significantly worse. The twelve were:

• Identify what are the core skills mix for nursing in social care
• Develop a career pathway with NHS nursing
• Develop nursing in social care as a positive career choice
• Address the inequalities in terms and conditions
• Rebalance the level of scrutiny and inspection
• Resource development in nursing specialisms in social care nursing e.g., dementia, neurology, geriatrics, mental health, palliative care etc.
• Develop and promote a positive image of nursing in care homes
• Work with HEIs to promote nursing in a care home setting as a positive career choice
• Positively address workforce issues such as emotional fatigue, mental wellbeing, stress and distress
• Address the issues of nurse recruitment and use of agencies.

If we start to work together, around a table of mutuality, from a position of professional regard rather than sector and clinical superiority, then we just might manage to prevent a crisis from becoming a collapse. Most importantly we will begin to give the amazing frontline care home nurses a sense of value, autonomy, respect and regard.

Donald Macaskill