Back to the Future ; staying where we are is not an option.

“BACK TO THE FUTURE”

 

Any night of the week, there are 33000 older people in Care Homes in Scotland, and  approximately 22000 of these are publicly funded. For the past 10 years these placements have been made under the National Care Home Contract.

I joined Scottish Care as CEO when the first annual settlement was being negotiated, and now as an Associate I’m working on the Reform of the Contract, to put in place the framework by which Care Home provision will be commissioned, funding levels determined and placements made for the next 10 years or longer.

Get it right and hopefully it will deliver improvement in both service quality and business viability. Get it wrong, and an already stetched and fragile sector, could be severely impaired. Whatsmore, the reform of the Care Home contract is likely to have a knock on impact on the reform of Care at Home.

But staying where we are is not an option: change has to happen. The local planning and commissioning environment has altered significantly with the advent of the new Integrated Health and Social Care Partnerships. The needs and dependency levels of residents have shifted over time.

The role of Care Homes, the services on offer, and the expectations of service users and their families have grown and developed, together with the demands of Regulation and Inspection. Partly as a response, the business models underpinning the sector have also adapted, with much tighter margins and pressure on investment. And, as if this wasn’t enough, we are going through the most challenging period in terms of the public finances for a generation.

Any new set of arrangements has to respond to all these factors, and find a way of combining the protection and efficiency of national benchmarking and negotiation with a new emphasis on local planning and flexibility. Moreover, we have to have at least the bones of this teased out and agreed by the end of the autumn. A tall order, yes, but potentially achievable, providing we have the continued support and commitment of all parties.

Watch out for updates and make sure you are fully connected to Scottish Care: The Bulletin, the Website, Branch Meetings, and of course, Yammer.

For me, retirement can wait, it’s time to power up the De Lorean and get back in there!

 

Ranald Mair

Associate, Scottish Care

Attending to care: a summer reflection

Earlier in the year Scottish Care published Voices from the Front Line which was the gathering together of personal stories of nearly 40 front line care staff working in the care home, care at home and housing support sector across Scotland. They were the stories of individuals who spoke of their hopes, aspirations, frustrations and exasperations with that most challenging of roles – caring for and supporting others. I was privileged to be one of those who conducted the interviews and many sentences and phrases have remained with me. One in particular continues to resonate in my mind as I tour the country talking to front line staff and providers alike. One participant said to me:

“The problem is, I don’t think we are paid to give time to people. We give care, we do the task, we have conversations as we are working … but we no longer have time, just to be with someone, just to be social. We’ve lost the time to really see what’s happening in someone’s life.”

 

Maybe that’s something you can recognise. The pressure of activity pushing out quiet space; time running away from us like sand in an hourglass, disappearing into the lostness of memory. Even at this time of year when we are supposed to be ‘re-charging the batteries’, resting and refreshing ourselves in the summer sun, there is still a pressure on time. Our traditional two weeks off never seem quite enough and so many folks talk about coming back as tired as they were when they finished up and within minutes of opening the laptop or starting the shift, being in need of the next holiday. Care can become a busy occupation rather than being an activity which allows reflection, validates the art of chat, and accentuates a space for being.

 

The scientist Alexandra Horowitz has written a brilliant study on how so preoccupied by busyness we can sometimes miss what’s in front of our eyes, how seeing isn’t an action but an art. A couple of years ago she published On Looking: Eleven Walks with Expert Eyes – the tale of a walk around a city block with eleven different “experts,” from an artist to a geologist, a toddler to a dog, and how she emerged with fresh eyes on what she witnessed.

 

Horowitz begins by pointing out the incompleteness of our experience of what we conveniently call “reality”:

Right now, you are missing the vast majority of what is happening around you. You are missing the events unfolding in your body, in the distance, and right in front of you.

 

By marshaling your attention to these words, helpfully framed in a distinct border of white, you are ignoring an unthinkably large amount of information that continues to bombard all of your senses: the hum of the fluorescent lights, the ambient noise in a large room, the places your chair presses against your legs or back, your tongue touching the roof of your mouth, the tension you are holding in your shoulders or jaw, the map of the cool and warm places on your body, the constant hum of traffic or a distant lawn-mower, the blurred view of your own shoulders and torso in your peripheral vision, a chirp of a bug or whine of a kitchen appliance.

 

She says that this ‘adaptive ignorance’ is there for a reason — we call it ‘concentration’ and it stops us from sensory overload and helps us focus on what is important for our sense experience at that particular time.

 

So we need such attention’ to survive but when it comes to relationships, to the art of caring, do we filter out things that we need and which are necessary?

 

Horowitz has said that her book is not, “about how to bring more focus to your reading of Tolstoy or how to listen more carefully to your spouse.” Rather, it is an invitation to the art of observation – we are invited to become:

Investigators of the ordinary, Sherlock characters in the midst of busyness.

 

The book is richly layered with hidden depths but what I want to focus on is a consideration of what is at the heart of the art of caring. I think there is a danger that when we commission and contract care we are oriented around the delivery of tasks thatcan be calculated, monitored, budgeted and thus remunerated. But what about that which falls beyond calculation and observation? I sometimes feel we have stripped the ‘social’ out of care on the basis of cost but in doing so, have  we stripped out the ability of carers to effectively care and support?

 

Caring and support is at a fundamental level about relationship. The effective carer sees beyond the observable; spots the subtle changes in behaviour which speak a tale no words can express; they read a story unfolding in the person before them; they can become the detector of life change which enables intervention and support. This becomes especially important where front line staff are increasingly having to have conversations about anticipatory care and end of life issues.

 

As we seek to re-consider and reform the way we structure care and support in Scotland will we leave room for such attention? Will we give space to our workers to have ‘time’ to be with rather than simply to do?

 

They want to – if we (and that’s a society ‘we’!) allow them. Systems which record visits from staff and time them to the minute might fit in a world of contracts but what place have they in arrangements which should be premised on the priority of building effective relationships, ones that make a difference to the lives of people?

 

One of the ‘experts’ who allows Horowitz to see differently, to develop her ability to ‘attend’ to the moment is a toddler. She says that part of toddlers’ extraordinary capacity for noticing has to do with their hard-wired neophilia – ‘the allure of the new and unfamiliar, which for them includes just about everything that we, old and jaded, have deemed familiar and thus uninteresting.’ (except as Horowitz says when we go on holiday – when we give space and time to the new – what she calls the holiday paradox).

 

I can well attest to the inquisitiveness and excitement of new discovery which a toddler enthuses into life. Perhaps then we need in Horowitz’s terms to spend more time ‘on holiday’, to see the world through a toddler’s love of the new, to move beyond our concentration on the familiar?

 

Think of what a difference we could make – what preventative excellence could be achieved if we commission and pay care workers to simply be, to sit, to see, to ‘attend’ rather than always to do, to record and to thus be monitored. Or is all that summertime dream? 

 

 

Dr Donald Macaskill

 

@DrDMacaskill

Dr Donald Macaskill

Scottish Care

www.scottishcare.org

07545 847382

Be somebody who makes everybody feel like a somebody

Tracy Viljoen:

I came into this role hoping to help to make a difference to others.  My Twitter profile states that you should “be somebody who makes everybody feel like a somebody”; something I genuinely believe in.

I’m sure anyone who knows me would say that “Tracy loves anything to do with leadership, she loves all that fluffy stuff” and they would be absolutely right. But, I’m glad to say that more and more people out there quite like the taste, the need and the success of ‘fluffy’.

North Lanarkshire is saturated with many wonderful stories of success, the problem is that staff however are not always great at blowing their own trumpet; they typically say “But that’s just what we do” or “it’s my job”. One care home had a resident with mental health issues and challenging behavior, he was quite unstable and sadly unhappy. He had always talked about owning a pet and so the care home manager and staff decided to take a SAFE RISK and arrange for ‘Gordy’; a bearded dragon to come and live with the resident.  Self-harming incidents have significantly reduced for this man and the staff can work with him in a far more manageable way.

A local frontline worker who was on nightshift when a resident took ill managed to stop a hospital admission being arranged by the GP – the lady had an anticipatory care plan (ACP) in place which stated very clearly she wished to remain at home, to die around loved ones and staff who knew her and how she liked to live. The worker used her AUTONOMY and SELF LEADERSHIP to achieve the desired outcome. I could go on and on, there are literally no shortage of examples of amazing things and great practice happening here in North Lanarkshire.

Last year I went to a workshop run by the amazing IRISS which was called ‘THE BIG IDEA’ and oh my word that’s exactly what it has turned into. They wanted a local partnership to work with, on any chosen project, in the new integrated world. Obviously I wanted this to be North Lanarkshire and 10 months later we are slap bang in the middle of an experience based co-design programme or as we call it EBCD. Developed by Bate and Robert it’s a methodology for working with groups of people who access support or care and the staff who provide this to improve services.

We have partners from all sectors, NHS Local Authority and social work involved in a project that is looking at the experience of going to Monklands A&E Department if you are a frequent attender who arrives in DISTRESS but not needing clinical attention. Such a worthwhile project and even today I met another provider who wants to be involved at the co-design stage.

There are so many examples of great projects locally which show innovation and great passion.

North Lanarkshire frontline staff in the independent care sector are creative and innovative and I have no doubt will continue to go from strength to strength if this work continues at both local and national level. These are exciting times for the sector!

 

Tracy Viljoen, Development Officer for North Lanarkshire

 [email protected]

Mob: 07446843547

Shining the light on SDS

The worst secrets are truths not shared.

It’s amazing how sometimes folks who you think should know about things, which seem second nature to you, catch you inside out. I had two such conversations recently. The first was from a care home provider who acted with shock when I said that someone assessed as requiring residential care has the right to a personal budget and to exercise choice and control over their care and support. The second conversation was from a daughter who reacted with equal befuddlement when someone asked her had she thought about the various options for controlling her mother’s budget whilst she was in a care home.

Now maybe I am being a bit disingenuous but as someone who has campaigned for and worked to raise awareness of self-directed support for nearly 20 years I am still astonished that two and a bit years after its inception so many folks do not know about the Social Care (Self Directed Support) (Scotland) Act 2013. Okay, I am not expecting folks to be experts in the minutiae of legislation but I would have hoped and imagined that this distance down the road that the basic rights and entitlements of older citizens were being advanced and promoted across Scotland. They are clearly not in every place.

The Act – and therefore that in practice means it is now a legal requirement – states that any individual assessed as requiring care and support and meeting the eligibility criteria of a local authority has the right to be offered four options as to how the budget allocated to meet their assessed and agreed outcomes should be spent. The so–called four options exist for all our citizens and many individuals have already had and are having lives transformed by being more involved in designing the support they require around their outcomes rather than having to fit into a pre-designed service or system. So choice and control has and is making a real difference to the learning disabled, to those with physical and mental health challenges, but what of the tens of thousands of older citizens?

That picture is not so clear. Undoubtedly many hundreds who live in communities are being supported to exercise choice through self-directed support and projects like our own Getting it Right For Older People are embedding their human rights at the heart of their care and support.

For those in residential care the story is less positive. Legally many of those individuals have the right to be offered control over their budget through three options, although not direct payments (option one). We have two test sites exploring the way in which all four options can be exercised. In both of these there is really interesting work going on - in East Renfrewshire and Moray - involving the local integration partnerships, providers and citizens themselves.

But what about the rest of the country? On the one hand, I hear a lot of platitudinal statements around older people and self-directed support. Folks will say – older people do not want the hassle that controlling budgets and all that that might bring. What presumptive discrimination! Who are we to limit the exercising of rights because it conflicts with our status quo systems and existing ways of working?
On the other hand, one of the challenges is the way we commission and purchase residential and nursing care home provision. Our present system is not designed to focus around the particularities of the individual – it is a one size fits all model. The reform process now underway has a real opportunity to personalise residential care commissioning and assessment. It will not be easy but it is I think necessary.

Personalisation is not just about ensuring that the services and supports that an individual care home resident receives are built around that person’s outcomes and needs. Personalisation, in the Scottish context, is about the principles of informed choice, collaboration, involvement and control. That practically means that individuals need to be individually assessed, their outcomes (unique to them) identified and then they need to be allocated a personal budget. Clearly this suggests a systemic change in the way we offer and deliver residential care. It is a task and a challenge for commissioners and for providers together. It is a process, a change, a journey that we need to work at together and with those who use services now and who will require supports. It is a journey we have delayed for too long.

The worst secrets are indeed those truths we do not speak of and tell. It is time for all of us to start talking about the rights of residents having access to the full extent and breadth of the law around self-directed support and by extension to their full human rights. It’s too important to keep it a secret.

Dr Donald Macaskill

Innovation at the heart

Legislation to implement Health and Social Care Integration came into force on 1 April this year. This brought NHS and local council care services together under one partnership arrangement for each area. In total, 31 Health and Social Care partnerships (HSCP’s) have been set up across Scotland.

At its heart, Integration aims to ensure that those who use services get the right care and support whatever their needs, at any point in their care journey. This brings a greater emphasis on enabling people to stay in their homes, or another homely setting, where possible, sharing their lives with their family and friends, doing the things that give life meaning and value.

The independent sector, being the biggest provider of social care in Scotland has a significant role to play in this programme. Though the largest provider of health and social care, our sector is not always associated with service excellence or seen as a true and valuable partner.

In order to change this I have recently set up The Learning and Innovation Group within Scottish Care. This will take the lead on sharing good practice, promoting the range of services provided by our sector and to support learning, improvement and innovation. I am joined by seven Local Integration Leads, all of whom are directly involved in innovative tests of change in their areas, by Becca Gatherum and by Jamie McGeechan. Jamie is our newly appointed Communications and Events Officer.

Those of us close to the sector see, on a daily basis, the commitment of our workforce, the high levels of skills and expertise within our teams, innovative practice, strong leadership and an absolute commitment to service excellence. This is a sector I am very proud to be part of.

The Learning and Innovation Group met for the second time yesterday and as anticipated, there was a really positive energy in the room. Given the significant challenges facing our sector just now, it was heartening to focus on the success stories and to remind ourselves why we do what we do.

Over the coming months we will share the learning from tests of change and innovative approaches to the delivery of health and social care. A variety of platforms and approaches will be used in order to reach as wide an audience as possible. These will include digital stories, publications and reports, presenting at conferences and events, videos, formal research, the development of a resource library and social media.  Jamie’s skills in communication will be evident to all! We plan to develop a section dedicated to innovation on the Scottish care website which will hopefully become a first stop for those interested in developing services. Whether looking at small tests of change, a major development or have an experience to share, we are interested in hearing from you.

I have many hopes in life, one being that the independent sector will get the respect and response that we deserve from our partners, the media and the public. We all have a role to play in this, I hope that my part in sharing the good news will help towards this.

 

Margaret McKeith

13 July 2016

Bringing human rights home

Over the last nine months Scottish Care has published two human rights documents, the Convention on the Rights of Residents in Care Homes for Adults and Older People and two weeks ago at the annual Care at Home and Housing Support Conference, the Convention on the Rights of People receiving Care at Home and Housing Support Services. Both were products of collaborative work where individuals who used support services articulated their sense of what constituted for them basic rights and quality in service provision.

Nearly two decades ago the Human Rights Act incorporated the European Convention of Human Rights into domestic legislation enabling individuals if they felt that there had been a breach in their human rights to take their case to a local court without having to have recourse to a court distanced from them in Europe. The whole process was badged as ‘Bringing Rights Home.’

In some sense that is what both of the Scottish Care Conventions have sought to do. They have sought to bring ‘human rights’ into the homes of individuals who use social care support whether they live in residential care or in the wider community. They have sought to make human rights something which spoke to their needs and aspirations, something which was real rather than a set of abstract concepts used by the media and politicians to score cheap points in a debate. As one of the participants said:

‘Human rights are ours.’

The First Minister in a speech in the Pearce Institute in Govan in September 2015 in addressing attempts to repeal the Human Rights Act spoke of the need to see the Act as a floor rather than as a ceiling beyond which one could not go or aspire.

“When the Human Rights Act was passed in 1998, the intention was that the Convention would provide a floor for human rights across the UK. That’s because it would be incorporated within the domestic law of all nations of the UK – through the Human Rights Act, and the different devolution settlements.

But the Convention was always intended to be a floor, not a ceiling. Devolved governments have the flexibility to go further, if we choose. And so complying with the Convention should not be the limit of our ambitions.”

(First Minister Nicola Sturgeon, Pearce Institute, Govan, 23 September, 2015)

The First Minister challenged civic and public society in Scotland to attempt to work together to achieve a context where human rights were at the heart of all we do in Scotland. In a small way the Conventions seek to contribute to that process.

The analogy of bringing rights home is a helpful one. To a considerable degree we have indeed brought rights home but I also suspect that we have kept human rights at the doorstep. Human rights have not entered into every room and corner of our ‘house of care’. We have, and are increasingly articulating the role human rights can play in the delivery of quality services which respect and enhance the dignity, voice and choice of those who use services and supports. The new National Care Standards will go a long way to embedding a rights-based approach to care. But if that is all we do – and that’s not to diminish that process – we will still be keeping human rights in one small room, a room about individual relationships and rights.

For human rights to mean more than just platitudinal rhetoric they have to infiltrate the whole of our health and social care system. Put simply you cannot have a human rights based approach to care and support without a human rights based approach to budgeting, to finance allocation and to commissioning.

It is all very well to require providers and those who work in care services to embed human rights at the heart of their work and services, but unless you have a system whereby human rights can direct the decisions we make about spending limited resources, and unless we change procurement processes to properly operate on a human rights basis then we are just tinkering with rights, we are just keeping human rights at the doorstep.

So at the Care at Home Conference we called upon our partners in Scottish Government and local authorities to work with us in building and developing a human rights based approach to commissioning and budgeting. We are partly there with good rights based procurement guidance, but we have a long way to go.

So what might such a model look like? Well it could perhaps be based on the widely recognised PANEL principles, which is an approach to what a human rights based approach means in practice. PANEL stands for Participation, Accountability, Non-Discrimination, Empowerment and Legality.

What might this mean for budgeting, procurement and commissioning?

 

Participation – People should be involved in decisions that affect their rights. So providers and those who use services should be key partners in strategic and local decision making, not informed or engaged in consultation after decisions have been made.

Accountability – There should be monitoring of how people’s rights are being affected, as well as remedies when things go wrong. If insufficient resource is allocated to enable an individual to be adequately supported then something is done to address this.

Non-Discrimination – Nobody should be treated unfairly because of their age, gender, ethnicity, disability, religion or belief, sexual orientation or gender identity. Is the allocation of public resources discriminatory for older people? Do we enable the same degree of choice and personal budget allocation to those over 65 as to those under 65, to those who live in our care homes and those who live in their own homes?

Empowerment – Everyone should understand their rights, and be fully supported to take part in developing policy and practices, which affect their lives. Do those who use supports adequately understand their right to involvement in decisions around their support and care e.g., in terms of self-directed support?

Legality – An approach like this is about going beyond the minimum legal requirements and mainstreaming human rights in services, policies and practice to make them run better for everyone.

The challenge is to fully bring human rights home, so that whatever part of our system of care and support from assessment to delivery, from budget allocation to workforce support, we have human rights at the heart and core, not rhetoric but a person centred approach that values the individual and gives real choice, control, involvement and dignity.

Scottish Care is committed to embedding both our Conventions and building upon that work in the months and years to come. So feel free to keep visiting us and join us as we bring rights home.

Dr Donald Macaskill, 5th July 2016

@DrDMacaskill

This blog builds on a speech delivered to the 2016 Care at Home and Housing Support conference on 23rd June. This can be seen at https://www.youtube.com/watch?v=X7uUf0v6phY

 

The independent sector – full of heart

Welcome to the first blog on our new website. Every month you will be able to read two new blogs, one from our CEO, the other from a guest blogger. Our aim is to inform you about what is happening in the independent sector, to encourage debate on issues of the moment and to promote innovation in the way that individuals are supported and cared for. We hope you enjoy them.

Last Sunday I had the privilege of taking part in the Royal College of Nursing 100th anniversary Congress which was held in Glasgow for the first time.

Together with the Director of the RCN in Scotland, Theresa Fyfe, and Scotland’s Chief Nursing Officer, Prof Fiona McQueen  I was invited to debate the contribution of third and independent sector nurses to care and health in Scotland.

My contribution was to reflect on the question ‘What needs to change for the independent and third sectors to be seen as equal partners in delivering health and care?’

To answer that question perhaps we need to ask something even more basic – What does it mean to be a nurse?

I’m probably not the right person to be answering that but it’s a question I can remember asking from an early age because every summer holiday I spent time with my aunt who was a district nurse in an island community… The archetypal navy-uniformed, Mini-driving, doctor-repelling, straight-talking Highland district nurse!

I remember asking her probably at a precocious ten years of age why she wasn’t a nurse in a hospital and amongst all her responses one thing stuck in the memory –

” I can get to know people, when they are ill and when they are well, I get to know them all, their sons and daughters, their neighbours and friends… And here I have time…  I didn’t have that in a hospital.

Maybe that’s a romanticised recollection of a ten year old but I remembered those words when recently I spoke to a nurse in a care home I was visiting. I was asking her what was different about nursing in a care home compared to a hospital. She said:

“Here I have time to get to know people, to sometimes become a friend, to nurse to the whole of the person and their family… It’s especially important at the end of life to be able to have known the person whose hand you are holding and who is spending their last moments with you.”

Time, relationship, being with, are some of the characteristics which mark out the especial circumstances of nursing in social care, whether in a care home or in someone’s own home. That’s not to say that they are alien to an acute environment but they are just more possible in non-hospital settings.

As we increasingly hear of the importance of people remaining at home or in a homely setting for as long as possible; as we read new policy initiatives such as the National Clinical Strategy or the Review of Out of Hours Provision, the potential and role of social care in achieving better health outcomes for people becomes a real one. In that regard nursing in social care settings becomes all the more important. There is real potential for those who want to nurse in care homes and in community locations to become a key ally in achieving the outcomes that people want for their lives. But to get there things need to change.

What needs to change for the independent and third sectors to be seen as equal partners in delivering health and care?

Perhaps not a lot for the person who is cared for at home and in a nursing home… but for the nurses themselves – the answer is that equality seems so very far away…

Do we really have equality when nurses in a care home setting are worse off (in terms and conditions) to the degree of around £6,500? Do we really have equality when nurses aren’t given the same opportunities for shared learning and development that colleagues in the NHS have? Do we have equality when countless nurses have told me about how lecturers in college dismissed care of the elderly as not ‘real’ nursing? Do we have equality when frontline nurses feel they have to justify working in a care home or in social care to their fellow professionals?

We need to give value to those who work in non-traditional settings, we need to honour and celebrate nursing staff in care homes and in the community as an essential contributor to the care and support of our communities. And yes value is in part by financial reward but its much more than that. It is about respect, being given a place, being listened to, being heard, having your contribution noticed and indeed celebrated.

The more nurses I have the privilege to speak to the more I know that despite the suffocating amount of paperwork and procedure that gets in the way- I might say unnecessarily so – it is the ability to form relationship, to nurture contact and to be with people that marks out nursing in an independent sector care home or care at home organisation as something which attracts.

In some essential truth nursing in the independent sector is authentic – it is genuine, honest, hard graft but at its best it is relational, human and valuable

What needs to change?  – we all do, society does, Scotland does. We need to change into a country that values those who have been labelled and limited by being described as old; we need to recognise contribution beyond location and value beyond number… Only then will nursing our older citizens be truly celebrated for the critical art it is.

Dr Donald Macaskill  Twitter: @DrDMacaskill