Happy New Year and Welcome to 2018.

Within the context of New Year’s Resolutions, and the focus on caring for and creating the ‘better you’ peddled within any one of the many self-help books promoted at this time of year, I see a shift from a focus on having less, to a focus on having more. To be health-‘ful’ by limiting what you give your body, to have more time by limiting how you use your time, to be richer by limiting how, where and when you spend your money: they all require a fine balance so close to being contradictory, and in complete contrast to the holiday feasting.

It’s an analogy which I see, in this time of austerity, being applied across the health and social care sector. Not to focus on cuts, but to focus on what we have and what we can do within that context. And whilst this appears to be a laudible approach, I have not yet found an ‘off-the-shelf’ self-help book on the health and social care sector.

This is because missing from the discussion is the reality that we have been working at this for over eight years now. At what point can we say that we have applied all of the efficiencies possible? Not to say that there is no place for review, but that a focus on what can be saved now leaves the sector exposed to the real risks associated with a failure to future proof.

Last  month I had the privilege to hear Professor Gillian Ruch speak at the Social Work Summit. She spoke about relationship-based approaches to service delivery, and raised the concept of austerity as an ideological choice about making budgets balance, not about looking at the needs of the population.

Often when we plan for our sector, we think about celebrating our aging population who may use health and social care services. But what we need to be aware of is that we also need to celebrate and value our aging workforce without whom the sector as a whole risks folding. Consideration then must also be given to the necessary interaction with and effect of this on the rest of the population, especially given the economic contribution of a sector which employs 1 in 13 Scots. But this has to happen not just in relation to workforce planning, but to all of the aspects of health and social care. To plan for the sector as a whole, we must to consider the needs of the population as a whole.

If carefully and thoughtfully planned, implemented and resourced, there are currently many opportunities for the sector; the reform of many of our partners, the new health and social care standards, self-directed support, integration, and so on. But my concern is that the pre-requisite context is not a given, and the current impact of winter on an already under-resourced and under-valued sector, means that change will come too late.

At the time of writing, we await the response of the Health and Sport Committee to the evidence given in relation to the ‘Save Our Bield’ campaign. Whilst I support the call to create an independent commission to review the crisis in the Scottish care home sector, I am wary that to consider the outcomes of this in isolation from the sector as a whole – from care at home through to acute provision – would be limiting and wasteful. What happens in one part of the sector will inevitably affect another, inevitably affecting the citizens of Scotland. And so the pressure is on to consider our vision for the future of care as a whole; a vision which values our population as a whole, the sector as a whole, and the contribution that it makes to the population of Scotland as a whole.

#careaboutcare

Mince Pies and Mulled-Over Wine!!

Well its nearly here, the adverts have been telling us since Halloween finished and we’ve seen plenty of premature Christmas trees peeking through the windows with their dazzling array of lights, and music playing within the shopping centres and on the radio – Yes it’s time to put on weight and blow all your earnings – Sorry what I meant to say is its Christmas time, a time for joy and celebration, as well as looking back as we face another year, at the year that’s gone and the year to come!

One film comes to mind at this jolly time, yip the Sound of Music, a firm favourite for families to sit around watching and singing along to the wonderful uplifting songs, whilst they sit uncomfortably full around the TV.

The song “Climb every mountain” rings true for me. Many years ago when I managed a Church of Scotland older person’s home in Helensburgh, we were celebrating the care home’s 40th anniversary. One of the many events we had was a fund raiser climbing Ben Lomond. Please note this is the one and only Munro I’ve ever climbed and whilst it was hard going up, coming down was also a challenge! My excuse now is a knee problem, honest!!

If it were not for one of my staff, who literally talked to me all the way up the mountain, which kept me focussed and from turning back, enabling me to concentrate on putting one foot in front of the other. Was it worth it? Yes; I emotively recall the moment as we looked down upon the vista of Loch Lomond, eating our well-earned sandwiches!!

Well, as you rightly will be asking, nice story and what has this to do with me, working hard within the social care sector? The parallels with climbing over obstacles – I found going up step by step a real problem. For many working within social care, this year has been a tough one (of many)! As I accompanied Donald on his tour of the branches within Scotland, common themes emerged: many providers face challenges of recruitment and retention of staff, continuity of business due to financial viability, stress of working within a seemingly over regulated care sector, dealing with complexity of care and an ever demanding commissioned service at low rates of reward, to name but a few. Many excellent providers have decided enough is enough and given up on the provision of care, having worked hard to provide quality care and employment. It has not been easy to make that decision, but forced into it by circumstances in many cases, out with their control. We hear within Scottish Care that this is now a common occurrence, with 9 out of 10 providers facing stress and major obstacles in continuity of service and care.

As was highlighted at our recent events for Home Care and Care Homes, this is a crucial time for our sector, and we need to work together in partnership (not necessarily harmony), as we walk up the social care mountain together. There are organisations like Scottish Care who are like that staff member who with her incessant talking, kept me company, encouraging and guiding me to take the next step, to watch for the pitfalls of a jutting rock or smelly bog, and just kept me going. We need to work and walk together with our partners to ensure that we are united in a common concern, keeping our head in reality, but looking upwards to our goal, just around that next bend!

Partnership does not just mean our sector, but those partners within Scottish Government, regulators like SSSC and the Care Inspectorate, Integration Boards, and those within health and social care to name a few. A recognition that we need to work together, putting aside differences, unblocking barriers and seeing beyond political mountains and obstacles. The people in Scotland deserve the best care and support we can offer, and this must be matched up with proper resourcing of funds, recognition for the important, complex work we undertake, and being regarded as equal partners within the care system. In this way we can indeed:

Climb every mountain,
Ford every stream,
Follow every rainbow,
‘Till you find your dream………..

In my last blog I mentioned my newly qualified niece, a nurse who chose to leave the NHS and work with older persons in the care sector. She still works there, and is investigating further academic possibilities within the sector. In addition my son in law worked for a large national retailer (one that’s open 24 hours a day!) but recently decided on a career change. He is now flourishing working in a care home. He loves being able to help those who need and deserve a kind heart.

So let’s stop the tide of folk leaving our sector, and encourage others to join us in a worthwhile compassionate job with the rewards of caring for many in their twilight years!

I wish you all a very Merry Christmas and hopefully a better New Year, so get those walking boots on, tie a rope round each other and together “climb that mountain”!

Swaran Rakhra

Over the last few days Scottish Care has issued a briefing paper to all MSPs and a subsequent media briefing.  In both we have called for our political leadership to prioritise social care funding in Thursday’s Scottish Budget.

At the Health and Sport Committee Inquiry into Care Home Sustainability on Tuesday 12th I was challenged by the SNP MSP Ivan McKee to quantify the gap of funding that I believe exists in social care in Scotland today.  I did so in calling for an additional £1billion over the next three years and not just for older people’s care.  I want to add to that statement in this blog.

First of all we need to, as a society, start to do the serious work of calculating the true cost of care.

At the moment we are all – from Local Government through to Integrated Joint Boards – engaged in the arithmetic of austerity.  What can we afford to do and what can we afford to stop doing.  I have already commented on the human dangers and cost of this game of chance – but it exposes the urgent need for us to move beyond the short term focus of a budget to the long term need to determine the true cost of care for the decades to come.  We have not done this work.  That is why together with others Scottish Care is supporting the call for a Commission on Social Care which critically must include an analysis of not just what care will need to look like but how we are going to pay for that care.  One without the other is meaningless.  Such a Commission has to be rights based, person centred in its focus and fully inclusive of all voices.

Secondly, the debate needs to move beyond the assumption that care is a cost we cannot afford towards recognising social care as an economic driver and contributor.

The 200,000 people who work in social care contribute greatly to the economy and those who are enabled to work by the care given to their relatives are a key economic benefit to our economy.  So why don’t we, like the Welsh Government has recently done, decide to make social care an economic priority, as equally worthy of investment and enterprise activity, just as significant a player as the next inward investor?  Why don’t we recognise the potential of social care to enable Scotland to be an economic driver and growth agent with the care of our citizens at the centre of our growth?

Lastly, where did we get the £1billion figure?

In their report on social care in late 2016 Audit Scotland said:

“If councils and IJBs continue to provide services in the same way, we have estimated that these changes require councils’ social work spending to increase by between £510 and £667 million by 2020 (16–21 per cent increase).”

From Social Work in Scotland report (Sept 16) 

Now I am the first to accept that we need to remodel the way we deliver care by drawing on community capacity but only to the extent that that is safe, enabling and enhancing of life.  I am the first to argue that we need to transfer resource from acute into community settings.  But the last year alone has shown in countless reports how far short we are in terms of a robust funding of social care.  So my call for £1 billion over three years is about 10% of the current annual spend, which is roughly £3billion.

Such a figure and level of investment would:

• Move the care at home and housing support sector closer to the delivery of a preventative approach which is outcomes focussed and time flexible; one built upon the outcomes of the supported person, respectful of the autonomy of the worker by training and equipping them better, and respectful of the provider by moving from time and task tendering to a commissioning model which is collaborative.

• Move us closer to really embedding the Self-directed Support legislation which is clearly not working for the majority but only for a small minority . Indeed a submission from COSLA to the Public Audit Committee for an evidence session on Thursday (14th) highlights the funding crisis for SDS.

• Move us closer to a situation where we are able to start plugging the gap Brexit is already creating in the workforce; to addressing the fact that 9 out of 10 organisations have care vacancies and we have a 31% nurse vacancy level; to meet the vacancies we fear might arise from the growth of the early years care sector.

• Move us to a context where social care really can be a career of choice, properly funded with terms and conditions which are appropriate for the astonishingly professional work undertaken and where we can continue to attract the best of our society.

• Move us to a place where we might be able to fund the developments around the reform of the care home sector in Scotland.

And in addition to all that we need to address how we are going to fund the plethora of proposals and initiatives which are impacting on social care for older people – be that the extension of Free Personal Care to those under 65 or the plans to extend Safer Staffing legislation to the whole of the social care sector; the embedding of the new Care Standards or changes in registration of the workforce; the right aspirations of the Palliative and End of Life Framework or the Third Dementia Strategy.

The gap between policy and legislation and implementation is widening; the gap between what is currently resourced and what is demanded is even greater. The cost of failing to bridge that funding gap will be met by the lives of the most vulnerable of our citizens who will be left unsupported and with diminished or no care.

The cost of the fiscal gap may be £1billion pounds over the next three years – the cost for citizens is being felt now and is immeasurable. The Budget offers an opportunity to cut some of that distance.

Dr Donald Macaskill

@DrDMacaskill

Donald’s Journey Through Enablement

Donald had been a teacher. At the time of the Improvement project, he was living alone in his flat. He had family but no children. Over time he became depressed and alcohol became a problem for him. He was diagnosed with dementia and his family took out a Power of Attorney.

By the time he was 75, Donald had ceased to care for himself. He stopped washing himself and his diet was very poor. His self-neglect was so severe that he was doubly incontinent and had a sacral pressure sore. In 2014, he was admitted to a nursing home and Scottish Care Enablement Trainers started training the staff in the Enablement approach. Though Donald walked independently without any aids, he isolated himself, rarely leaving his room. He spent hours in bed, uncommunicative and very challenging with staff when they tried to encourage his personal care. It became obvious that he engaged best with one staff member. Though she only worked two days a week, he allowed her to tend to his wound.

The Enablement Trainers guided care home staff to write support plans which ensured that all staff behaved in a consistent manner with Donald. They were to warmly and gently engage with him to win his trust but allow him to set his own pace. The staff did not give up on him and gradually, over nine months, Donald started to engage with his daily care. His family remained supportive and through them it was discovered that Donald loved dogs. Therapets were brought in for him.

By 2015, Donald was no longer incontinent, he washed daily and changed his clothes appropriately. Regular medication and a nutritious diet improved his mood and bodily functions. He liked to help so he was given the task of serving the drinks at mealtimes. Then he began to help with the garden, enjoying weeding and picking up litter. He took such an interest in his life that he would edit his own support plans, deleting certain instructions and writing ‘I can do this’. It was important to him to remember staff names so he wrote them down and always addressed staff by their proper names. He expressed a desire to go into town, so working collaboratively with his family, Donald started taking the bus into Aberdeen. Initially he was accompanied but over time he became fully independent.

By 2016, it was mutually decided that Donald could leave the nursing home. He has since moved into sheltered accommodation. Before he left, he got a card and had each staff member sign it as a memento.

The following is the text of an Address which was delivered by Dr Donald Macaskill, Scottish Care Chief Executive, at the start of the conference ‘Raising the Standard: older people’s care and human rights.’ held in Glasgow on Wednesday 29th November.

The Perils of Human Rights Complacency

Human rights and their abuse are in some contexts all too apparent, they are in your face, wholly transparent, and easy to recognise.

It is easy to see the relevance of human rights in the prison cell where political opponents of a regime are tortured; in the queues of malnourished children waiting to be fed fleeing from Myanmar; in the faces of individuals devoid of hope surviving in a place where economic corruption benefits the few at the expense of the many.

But it is much less easy to see human rights and their potential abuse in places where a veneer of material wealth is the norm; where people still get access to care and health services; where poverty is hidden; where there may be voices of protest but rarely voices of pain; where the language of human rights has become commonplace, part of the political grammar and rhetoric.

Elie Wiesel, the prominent Holocaust survivor addressing President Clinton in 1999 delivered a speech called ‘The Perils of Indifference.’ In it he said:

‘Indifference elicits no response. Indifference is not a response. Indifference is not a beginning; it is an end.

And, therefore, indifference is always the friend of the enemy, for it benefits the aggressor — never his victim, whose pain is magnified when he or she feels forgotten.’

Wiesel was pointing to a powerful truth, namely that to be indifferent to the plight of another robs that person of hope, it takes promise away from them and removes the dream that things might change.

I would contend that in our own context we are neither faced with the direct affront to or the assault upon human rights; nor indeed the casual indifference where openly and publicly a society, its people and representatives do not care about human rights. That is not our society.

But rather than both of these positions I want to suggest that in our society we are today faced with a human rights complacency – and that that complacency not only eats at hope, but limits action and serves to negate protest.

This morning I want to, paraphrasing Elie Wiesel, say that we are in danger of the perils of human rights complacency – right here and right now in Scotland.

And why am I making that assertion?

Well to begin with what do I mean about complacency? To be complacent is to be satisfied with a situation to such an extent that you cease to try harder… if things are not broken don’t waste the energy in trying to change them, don’t expend time in seeking betterment. Find other battles to fight.

So where do I see this complacency?

First of all, we do indeed have a solid basis of human rights both in legislative and policy terms. Indeed, at times I often hear how we are admired by others for the way in which human rights are at the very heart of our legislation and policy, not least social care and health policy.
Human rights complacency happens when stakeholders delude themselves into thinking that the articulation of rights is equivalent to the realisation of those rights. Merely having excellent human rights based legislation does not give the citizen the ability to realise and access those self-same human rights.

In too many instances from Self-directed Support to the proportionality and inclusion of decision making for those with limited capacity – we talk a good game but the reality is less than what we would desire.

The failure to invest, to monitor, to hold accountable and to hold to task those who have acted against the human rights enshrined within the Self-directed Support Act should shame us all – but the peril of human rights complacency is that we issue an Audit report, utter some rebuke, gain some negative media headlines but effectively fail to really challenge and change the systemic breach of those human rights.

So today across Scotland we will still have instances where hundreds of older people will fail to be properly assessed, informed of what budget they have to spend, be given real choice for their care and support, and if they want to, be able to alter that package of care and do something new and different. For too many there is no choice. No transparent offering of information to enable folks to make decisions. Rather, there is a complacent attitude that the old don’t want the fuss or trouble of taking control of their lives.

Secondly, with a such a rich heritage of anti-discrimination practice enshrined in the Equality Act, we might well consider as a society that in Scotland we treat all people with equality, regardless of distinctive or minority characteristic, recognising of course the need to treat some people differently in order to ensure such equality.

But any successful equality and human rights legislative framework demands that it is used to rigorously assess the impact of policy and practice change. So where are all the human rights impact assessments on some of the significant plans and proposals being put forward in the last few weeks by some of the Integrated Joint Boards or Health and Social Care Partnerships? If you are changing the shape and face of care as some of these will have the effect of doing- it is absolutely an act of care and human rights complacency not to rigorously assess what such changes might mean for some of our most vulnerable citizens.

Indeed, some of the proposals which have been published, though they may be couched in careful language, are presenting a limited, skewed and partial picture of the reality of care for older Scots. They are presuming upon the existence of family and informal care capable of taking over from professional paid care; they are endangering our older citizens with a casual arithmetic of austerity which is in turn in danger of saving money but costing lives.

Human rights complacency exists where we do not have robust follow through and assessment of whether or not we are walking the talk. It is a fundamental plank of the human rights framework that we undertake action where we identify that there is a need to mitigate proposals or plans which act against people and their dignity.

Thirdly we pride ourselves in Scotland, do we not, as the inheritors of the common man kailyard of Rabbie Burns, that we treat all women and men as sisters and brothers – as equal in community with one another?

But perhaps it is this romantic notion that evidences the most damaging complacency of human rights. If we truly open our eyes what we see in Scotland today is a subtle, sometimes hidden, undercurrent of unequal treatment and discrimination. The primary victims of that are the old, the frail and the infirm.

It is surely nothing less than discrimination that we do not give the same opportunities to older citizens that we give to those who are younger; that in the evidence of the recent Scottish Care report, Fragile Foundations, that we treat the mental health needs of older Scots as being of less significance than those who are deemed as adults; that we invest £500million in new provision and services for young children and early years but seek to continually slash and reduce what we spend on the old and infirm. This is not to create a generation war, lest some think it is, it is rather a calling into question the human rights basis for budgetary decisions which disproportionately and negatively impact upon the old. We are engaged in a human rights complacency if we imagine we can achieve human rights in practice without a rigorous human rights impact assessment on the way we choose as a country to allocate our resources and spend our finances.

As we consider options available for our nation in the days during which our budget is set, where does human rights fit into these decisions and priorities? Are our politicians balancing human rights in the political equation? I would love finally for someone to see social care not as a burden, as a cost, as a drain, but rather as opportunity, as asset, as an economic driver, worthy of investment, growth and innovation.

Fourthly and lastly, we have seen brought into play an excellent set of human rights based Health and Care Standards and we will spend some time this afternoon focusing on these. A lot of energy and work has been put into their development, articulation and acceptance by a wide range of stakeholders. But yet again merely having a set of indicators and Standards doth not a human rights system of care and health make.

Where is the specific resource to enable those who hold these rights to understand their meaning and relevance, and thus to exercise them? Where is the resource to enable those tens of thousands of workers who will be responsible for putting them into practice and for fulfilling them – where is the resource to train, equip, build the understanding and confidence of the workforce?

There is a complacency that assumes embedding rights costs nothing – if we are serious rather than just playing for adulation, applause and soundbites – then we need to resource the embedding of human rights. To fail to do so is complacency.

There is a fantastic potential in the realisation of human rights. Lives are changed, people gain a sense of purpose, equal treatment sits at the heart of services, dignity is enshrined to protect the most vulnerable. Raising the Standard is the challenge which lies at the heart of all human rights policy and action. But we are not there – in fact, I fear we are, at this present time losing rather than gaining our ground. To paraphrase an oft quoted aspiration of the First Minister – we are not so much reaching beyond the ceiling of human rights but we are starting to dig down into the cellar.

So throughout today we will be encouraged to see the potential of realising our human rights, of raising the standards of human rights for older people, but let us not be complacent that we have a short distance to travel before we live in a society where rights can be taken as normative and accepted by all.

Elie Wiesel said:

‘The political prisoner in his cell, the hungry children, the homeless refugees — not to respond to their plight, not to relieve their solitude by offering them a spark of hope is to exile them from human memory. And in denying their humanity, we betray our own.’

I believe that we also betray our humanity and lessen our society, if we become so complacent that we fail to recognise the subtle diminishing of rights, the closed ear to the cries of those lonely and isolated; if we fail to hear the fragile voice of those frail with age, but still seeking equal treatment and dignity. To do so does indeed demean our humanity. It is a human rights complacency that is now taking root in Scotland.

Dr Donald Macaskill
CEO, Scottish Care
@DrDMacaskill

One of my lifelong sources of irritation is that I am ridiculously short-sighted which makes the daily middle aged misplacement of spectacles really annoying.

It took me a long time to discover there was a ‘Sunday’ name for all this. According to the dictionary ‘myopia’ is the name for near sightedness and apparently it is becoming more common. But it also carries another meaning for to be myopic is also to have a lack of foresight and intellectual insight.

As I sit writing this blog there seems to be a growing tendency towards myopia amongst some of the health and social care planners and strategists that are influencing decisions across Scotland today.

Scottish Care publishes its latest report on nursing today. It paints a fairly depressing picture. There are increased vacancies, exorbitant nurse agency costs and more nurses leaving care homes to join agencies than ever before.

In response Scottish Care is working with colleagues from the Chief Nursing Office along with others to address many of these challenges. But as well as those interventions I have a concern about a wider, maybe even systemic, failure to appreciate and acknowledge the changed clinical environment we now live and work in. This is especially noticeable in some of the debates around the future of nursing in the care home sector though by no means uniquely there. There is an unwillingness to accept the significantly enhanced levels of dependency of those in care homes who require 24/7 clinical support.

Alongside this in the last few days I have read plans and proposals which effectively imagine a greater dependency on informal care in our communities and a greater reliance on an already fragile homecare sector across Scotland.

To be independent whether in our own home or in a homely setting must surely be the ambition we all want to achieve for both ourselves and our loved ones. But independence in the sense of living on your own supported by family or others is not possible and cannot be possible for everyone. The mantra of independence at all costs may seem to cash stretched Integrated Joint Boards as an easy solution but in essence it is a dangerous road to start walking down. Independent living without appropriate safeguards is neither responsible nor is it safe.

Over the last decade we have seen an enormous change in the number of people being supported to live in both care homes and in the community with enhanced and significant clinical care needs. The description I hear the most from staff is that ten years ago most people walked through the doors of a care home whereas now most have such high levels of support needs that they are rarely able to self-mobilise.

In our communities too there has been a growth in the number of people being supported to live independent lives and for whom a decade ago a hospital or care home might have been the only options open to them.

So in general, therefore, there has been a rightful re-orientation from clinical to community settings. But this has its limits. To continue to maintain or place people with high levels of clinical care in the community without an adequacy of clinical support and appropriate resourced clinical governance either in care home or their own home is irresponsible and unsafe.

Too many family carer groups tell me they are on the edge of exhaustion. They can’t have yet more placed upon them. Too many professionals recite instances where the risk of those they care for is unacceptably high and we are only a hairs-breath away from a serious incident.

There is a real danger of a care myopia which allows us to make care decisions based on the right principles but with the wrong outcomes. Quality care cannot be cheaply purchased nor delivered. The social care system in Scotland is in need of radical re-orientation and prevention is surely the key. But prevention is only possible if there are adequate supports to enable it and we are in danger of losing these. Preventative care cannot be developed within the parameters of greater risk.

At the moment I am witnessing a real lack of vision in an awful lot of the plans and proposals I see. The tendency to reach for the fiscal scissors and cut out services is a reactive one with little basis in clinical or care reality. It is evidence of limited imagination and even less far-sightedness for what care and support needs to be in the Scotland of the near-future.

Those who are in need of care, those who are vulnerable in our communities, who cannot and should not be left on their own in the name of ‘independence’ and ‘self-management’ deserve better than the restrictive visions of a limited, over-stretched, risky care currently being offered as the future in some places; for they are a short-sightedness based on fiscal criteria which serve us poorly – they are nothing short of a care myopia.

Dr Donald Macaskill

@DrDMacaskill