Spirituality is everyone’s business. Scottish Care has recently launched its latest Care Cameo. Its central theme is spirituality and spiritual care. But what is it all about? Two definitions to start our reflection: “Spiritual care is that care which recognises and responds to the needs of the human spirit when faced with trauma, ill health or sadness” (NHS Education for Scotland,) “A person’s spirituality is not separate from the body, the mind or material reality, for it is their inner life. It is the practice of loving kindness, empathy and tolerance in daily life. It is a feeling of solidarity with our fellow humans while helping to alleviate their suffering. It brings a sense of peace, harmony and conviviality with all.” (Spiritual Care Matters, NES 2007) As will be clear once you start exploring the Cameo, there are many divergent views on what is meant by ‘spirituality’ and also what it means to offer and deliver ‘spiritual care’. This is for some people a difficult area both to explore and to engage with and that is precisely why we decided to dedicate a Cameo to this important issue. It is written by three authors with a particular experience in working in this field. Spirituality has to do with the heart and pulse of being human. It is the soundless language which communicates our deepest emotions of love, anger, fear and belonging. It is the rhythm which gives form to many of our innermost thoughts and feelings. It is the space where we rest in the awareness of meaning beyond comprehension and experience beyond description. To offer spiritual care is to give opportunity, time and place to enable an individual to explore and to express who they are as a human individual. As we seek to embed a human rights-based approach to care and support through the new National Care Standards it is an important that we not only understand the role of formal religion and belief systems but wider understandings of spirituality. As a care sector and as carers we need continuously to explore what this may mean for the work we do and the services we offer. Spiritual care is care both at the margins and at the centre of the life experience. The way we commission care and support at the moment in Scotland leaves very little room for spiritual care. For spiritual care is a care that needs space, relationship, time and the chance to grow and nourish in a mutual dynamic of respect and understanding. Spiritual care happens in the ‘touching place’ between the carer and the supported person. It cannot be pressured into allocated seconds in a task-oriented approach. So when, I wonder, will our commissioners prioritise spiritual care? For if we are truly commissioning to the new National Care Standards then there has to be space to be spiritual in our care giving and there has to be funding to enable that space and time to happen. I hope you will read the Care Cameo, and I have no doubt it will raise as many questions as it will seek to offer answers, but I hope you will find it, as I have, a thoroughly interesting and thought-provoking piece of work which is all about putting the individual and their holistic needs at the heart of person-led care and support. Dr Donald Macaskill
It is now over ten years since the Adult Support and Protection Act (ASPA) became law in 2007. As someone involved in its early stage development and roll out it is amazing to think that ten years has passed. Scottish Care was funded at the time to develop a programme of training and support, called ‘Tell Someone’ , which brought the Act alive for those working in frontline care in care homes and homecare services. It is still a resource which is much used today. Last week the Care Inspectorate, Her Majesty’s Inspectorate of Constabulary in Scotland (HMICS), and Healthcare Improvement Scotland (HIS) published a ‘Joint Inspection of Adult Support and Protection’, the first inspection looking specifically at how well the agencies responsible for keeping adults safe are working together to protect those at risk of harm. The Inspectors looked at a representative sample of six local areas: North Ayrshire, Highland, Dundee, Aberdeenshire, East Dunbartonshire and Midlothian. In each area, they looked at the experiences of individual people, the extent to which key protection processes are in place, and how well local leaders were performing. By and large the Inspectors found that there was evidence in most areas that adults at risk are safer and better supported because of the Act and the supports which underpin it. This is positive news but conversations with those who work in the world of adult protection and safeguarding would caution against over assurance that we have got everything completely right. My concerns are as follows:
- Quite rightly the Adult Support and Protection Act has been lauded as a very solid piece of legislation and it is much envied elsewhere in the United Kingdom. Part of that admiration is that it has a set of overarching and underpinning principles which are firmly rooted in the Human Rights Act. The concepts of ‘least intervention’, of ‘proportionate response’, of ensuring any action ‘benefits the individual’; all of these are squarely human rights principles in practice. However, there is a legitimate growing concern that at times the actual practice of the Act is paying only a passing lip service to the principles which lie at its heart. At best I think we need to do more to assess whether or not we are intervening and utilising the Act in all necessary circumstances and instances. For instance, are we using ASPA within health settings as much as we should?
- When the Act was being implemented a lot of good work was undertaken in the care home sector and that resulted in the development of confidence and skill amongst the care home workforce. My concern is that some of that earlier inclusivity has been lost. Are care home managers and staff as fully included in the implementation of the Act , e.g., in case conferences, in multi-disciplinary reviews, as they might be?
- I am less convinced that there has been sufficient and appropriate attention given to issues of adult protection and safeguarding for our care at home sector. There are real challenges of lone working and being able to identify and act upon concerns of harm. Associated with this is the inevitable issue of resources. As training and learning budgets are being slashed by contractual practice across the country, are we properly equipping our social care workforce in the community to properly understand issues of adult protection, to be able to recognise the signs of harm and to have confidence in knowing what to do if they come across concerns? I am not convinced in all instances that this is the case. It is time for us to do some serious capacity building within specific sectors.
- On a wider front the Act did a lot to try to change the cultural and popular understanding of adult protection. If you look at the legislation and its associated Guidance you will not find the word ‘abuse’. At the time of its development there was a considerable debate on this matter, but the idea won out that ‘harm’ needed to be used as a term to identify a wider range of behaviours than the word abuse described, including actions which were pre-meditated, conscious and deliberate, but also unintentional and unplanned behaviours, such as potentially neglect. I am not convinced that at a popular and societal level this broader understanding of what constitutes harm has gained much ground. That might be because we have failed as a country to properly invest resource in public awareness around adult protection and what constitutes harmful behaviour.
- A related issue is the extent to which despite the Act’s existence for over a decade we have seen a rise in behaviours which have been discriminatory and thus ‘harm-full’. This is especially a concern when we consider the sharp rise in discrimination and hate on the grounds of age. How, one might ask, does the reality of increased discrimination and harm on the basis of age relate to the implementation of the Act when it impacts on someone who is defined as being an ‘adult at risk’?
- At a national level I have expressed a personal concern that we now no longer have an Adult Support and Protection Forum. Up until three years ago this was a body which brought together individuals from diverse sectors with a common purpose for improving practice, disseminating knowledge and advancing the issues around adult protection. Its loss has been a matter of significant concern especially at a time when the lessons of the benefits of national multi-agency co-operation around child protection have become so obvious.
- My final observation about the Act is that, in part because of financial constraint, we have as a society in our practice focussed on only one part of the legislation, namely the ‘protection’ of individuals who might be at risk. This is a real disappointment. The originators of this legislation envisaged the importance that as adults individuals who might require protection would of necessity benefit from ‘support’ to enable them to be free from harm. We have failed to adequately focus on a permissive, enabling approach to safeguarding and perhaps unsurprisingly have concentrated on the ‘protection’ element. This is to miss the primary energy of this ground-breaking legislation. It is to fail to recognise that in our vulnerability we all need support to prevent us from being the object of another’s wish to harm. It is to fail to give equal weight to Adult Support as much as Adult Protection.
We have come a long way in ten years. Practice is on the whole sound. But it is time for us to re-discover some of original intent and energy within the Act and its Guidance and to re-invigorate a system of right’s-based support which fosters true adult protection. Dr Donald Macaskill @DrDMacaskill
What is the link between Prof. Jason Leitch, pressure ulcers and Krakow? Up until March of this year I would have said “none”. However, an invitation to co-present a poster at this year’s European Wound Management Association Conference (EWMA) made the link very clear and was an excellent opportunity to fly the flag for Scotland’s independent sector on an international platform.
Prof. Jason Leitch (Clinical Director, The Quality Unit, Scottish Government) announced his aim that pressure ulcers were to be reduced by 50% in all care settings by December 2017. He shared this with delegates at the NHS Scotland event in 2015 and set the Reducing Pressure Ulcers in Care Homes Improvement programme’s wheels in motion.
This programme was a collaboration between the Care Inspectorate, Healthcare Improvement Scotland (Scottish Patient Safety programme) and Scottish Care, and saw for the first time, our three organisations working on such an improvement project. This is detailed on the microsite developed as part of the process www.pressureulcers.scot.
Having being involved in this since the onset and very aware of its success, I was delighted when Joyce O’Hare (Improvement Advisor, Care Inspectorate) took the lead in developing a poster abstract to be submitted to the EWMA conference being held in Krakow. Joyce’s abstract was accepted and we were invited to prepare a poster. With an emphasis on collaborative working, integration of health and social care and improvement methodology, Joyce worked with Jill Gillies (HIS) and me in preparing and submitting the poster. We were delighted when this was selected and we were invited to present this to delegates from around Europe. With support from Scottish Care and the Care Inspectorate, Joyce and I set off for Krakow on 9th May.RPUCH postert Krakow 2018
Although our presentation was short our poster was on display for the duration of the conference. Our collaborative approach, the independent care home sector, the role of the Local Integration Leads, our commitment to improvement and the opportunities created by integration were all shared. With an audience consisting of such a wide range of health professionals from across Europe we feel we certainly put our sector and organisations we represent on the map.
Partners for Integration and Improvement
Test of Change
We are living and working in an inter-connected environment. The use of email for sending messages, exchanging information and assisting with workflow is common place across the public sector. There are many links between the health and care system, but it’s often difficult for health and care professionals to share information. Access to the right information about patients and users of services at the right time is essential to ensure continuity of care.
When patients are discharged from hospital, care homes are still receiving information about that individual by fax, in person or post. Often, key pieces of information are not received at all. This makes it difficult for care homes to prepare for a new patient’s/resident’s arrival or the return of a resident who has been in hospital. As well as being inefficient and slow, paper-based communication is not a secure delivery method.
Lothian Unscheduled Care Board have agreed to fund costs for a one year test of change –Secure emails access for all care independent care homes (circa 103) in Lothian. Each care home will be provided with up to three nhs.net accounts for a period of one year. Care homes coming on stream during the next few months have also been included in this test of change.
CEO’s or equivalent of each individual independent care home must sign the Data Sharing Contract, as must the staff identified as secure email recipients. Following on from this each identified recipient must sign a NHS Lothian User ID Request Form
The provision of secure emails to all care homes in Lothian will markedly improve communications between care homes general practice and social work. Specifically, it will enable faster discharge of patients through the electronic communication of patient assessments and subsequent discussions rather than this being by post.
Secure email will transform how healthcare organizations in Lothian share and work collectively to provide coherent joined up services for the people concerned the public. Good timeous information underpins good care and on-going support.
Care homes will benefit greatly from having a consistent electronic transfer of medical discharge summaries (typically sent to a GP within 24 hours). This will enable the care home to fully prepare their service for supporting people discharged from hospital by preparing for the persons needs well in advance of their arrival.
Pre admission assessments will be carried out and shared timeously thus supporting early discharge to the care home and help improve the efficiency of the discharge process generally.
Secure emails offers the potential to share Anticipatory Care Plans from statutory services. E.g Person moving into a care home. Referrals, assessments, multidisciplinary review summaries, flu vaccine consent forms will be immediately accessible to care homes. Opportunities for Tissue Viability, Health Protection, Care Home Liaison, CPN’s and pharmacy specialists instant ability to network and support and safely communicate sensitive information with care home staff.
Other benefits are the ability to send and receive patient/resident information quickly and securely. No confusion from messages taken over the phone or illegible writing on faxes. Improved awareness of care home staff in relation to information governance rules on handling patient information. Secure paper trail in place for example, time emails were sent, removal of fax machines which are costly and require maintenance. Costs of postage for partnership reduced. Reciprocal communication time by health and social care professionals markedly reduced and this initiative supports positive change in service.
This test of change Secure e-mail access for care homes in Lothian should seek to demonstrate measurable improvement in outcomes either directly to individuals or indirectly through improved service design and delivery. There will be on going monitoring to make sure the project is achieving the desired results and to demonstrate the impact of the project to others; as well as to identify issues or problems as they arise within the project so that actions can be taken to change or redesign the project while it is in progress.
Local Integration Lead, Edinburgh City
Big Community: the return of the Big Society
In recent months there has been a developing discourse which goes somewhat like this:
‘In the face of the growing demographic challenge and pressure on health and social care services coupled with acute financial austerity, we need individuals in their communities to take more responsibility for the care and support of their family members and neighbours. This is after all not the responsibility of the State but rather the individual. If you are ill, we will treat you as a last resort after you have self-managed your condition and used whatever technology that is available which will avoid expensive direct human intervention. We are no longer able to pay for you to be fully independent and achieve what you may want because we simply cannot afford it.’
Maybe I am being a little generalist and overly simplistic in that description, but I suspect not that much. Is this not broadly the message which the Edinburgh Integrated Joint Board has been communicating to the good folk of the capital? Is this not the underlying message from the Westminster administration? Is this not the message which landed Glasgow’s HSCP on the front page of the newspapers with their threat to remove (after minimum consultation of) sleepovers in the lives of some of that city’s most disabled citizens?
So somewhere out there at the bottom of the garden is an empathic, time-rich, resource-endowed group of individuals just waiting to step in because the State (also known as that group of individuals created and employed through the taxation of the populace) chooses no longer to afford the cost of care. Oh and as in the past, it is the role of the female members of the community to do all this work. After all care is a woman’s work.
And as I hear and read this developing and subtle narrative where some of our most vulnerable are expected to be supported for less resource by utilising the untapped potential of the community, accessing community ‘assets’ then part of me philosophically says “Yes, it’s good that people have more control and choice, autonomy and power; that people do need take responsibility and collaborate with professionals, to self-manage and exercise responsibility. But ….”
Are we in danger here of unintentionally slipping into a new mode of social responsibility and a new model of social care without having thought through the full consequences of such a move? Is there a danger that decisions essentially made on financial grounds and dressed up in the rags of a social philosophy, are taken without a robust and appropriate moral, ethical or human rights underpinning? Is this idea of the Big Community not somewhat resonant with the failed and flawed concept of the Big Society? Remember the Big Society?
Every political era and every politician looks for a catchy phrase, slogan or idea which will capture the public mood and define them as distinctive and visionary. For Tony Blair in the halcyon days of New Labour it was the Third Way, though we weren’t that sure what the other two were. For Bill Clinton it was ‘community’ – a word which appeared more in his pre-presidential speeches than any other idea. For Gordon Brown it was a brief flirtation with the idea of Britishness. For Obama every change was possible. For Trump it’s the myth of ‘false news.’ But for David Cameron it was at least before the Brexit Fall– the Big Society.
‘The Government indicated that the Big Society is communities feeling empowered to solve problems in their neighbourhood, having the freedom to influence and discuss topics that matter to them, and a more local approach to social action and responsibility.’
The term “Big Society’ aimed to create a climate that empowered local people and communities, building a “big society” that would take power away from politicians and give it to people. It aimed at “integrating the free market with a theory of social solidarity based on hierarchy and voluntarism”.
Doesn’t that all sound remarkably similar to some of the political rhetoric that we are hearing today about the need for social care to be devolved to the individual; for communities to use their assets rather than the State to support and provide anything other than life and limb supports?
I think we are in the midst of an unarticulated political paradigm which I will term as the ‘Big Community.’ Its failings are not insignificantly the failings of the Big Society. Primarily it is a concept based on a naïve and utopian understanding of community or society. Its foundations are therefore weak and insubstantial. We are not in a bucolic age where people are living in families in geographically proximate communities. We are not living in an era where individuals have so much time that they can spend it in activities to help communities become more cohesive. Most are doing two or three jobs to pay for the mortgage. We are not living in a time when we can be assured that skilled clinical health and social care is being delivered by the State and what we do is an added extra in an individual’s life. Indeed it is an insult to the professionalisation of social care work to suggest that ‘care’ can be undertaken by anyone – that it doesn’t require training, ability and developed skill.
I am more and more convinced that just as the Big Society was called out as a naïve political mantra divorced from the reality of fractured and failing communities, that we now need to challenge the rhetoric of the Big Community and insist that we adequately fund social care beyond our already high levels of eligibility; that we adequately remunerate and resource social care staff and organisations so that we attract the best and deliver real quality; and that we help to use community assets to really advance our togetherness and not to paper over the cracks caused by austerity and fill in the gaps of a failing national health and care system. If not then neither community nor society are big but detached, distant and absent.
Dr Donald Macaskill
At a recent conference I attended one of the speakers made a statement almost as if it was a fact that ‘the social care sector has a Luddite attitude to technology and digital innovation.’ When I’ve mentioned that sentence to a few others they have confessed some agreement with his sentiment. I want to suggest in this blog that it is a wrong representation on two grounds. The first is that it’s historically inaccurate and more importantly, the second reason is that it couldn’t be further from the truth.
The Luddites were a radical group of English textile workers and weavers who just over 200 years ago in the Nottingham area destroyed weaving machinery as a form of protest. The Luddites were not against the machines themselves but against how they were being used to undermine what today we would describe as ethical working practices and health and safety. Unfortunately, the term has become adopted to mean someone opposed to automation or new technologies per se. What has been lost is the sense of protest against the misuse not the existence of technology and automation.
Before turning towards the second assumption that the care sector is antithetical to technology I want to reflect a little upon the critical contribution of technology.
Paul R Daugherty and H James Wilson have recently published a book called ‘Human + Machine: reimagining work in the age of AI.’ It is a very good read and explores the potential of Artificial Intelligence (AI) in the work environment against the framework of a generally suspicious cultural narrative. They explore the way in which popular culture not least in examples like the ‘Terminator’ movies or ‘2001: A Space Odyssey’ suggest a polarised man versus machine view of things often depicting a future when human beings are replaced by machines. The knee-jerk reaction and negativity is echoed when we explore the debate around social care and technology.
Daugherty and Wilson forcibly argue that key to understanding the contribution of AI in any context, including the care sector, is to understand its transformational power. If we only think of AI in social care as something which will automate certain functions and tasks, then we will miss its power. Rather they argue that we need to recognise the potential of AI to complement and augment human capabilities. They envisage organic teams that partner humans with advanced AI systems. Can we imagine a mixed care team of robots and humans? Is that the stuff of dreams or nightmares? For some it is already a reality as evidenced in some Advinia care homes in England.
The authors suggest that we are about to enter a ‘third wave’ of societal and workplace transformation. The first wave, they argue, was when people like Henry Ford introduced ‘standardised’ procedures. The second consisted of the automation of processes. The third, they suggest is the ‘missing middle’ where humans and machines interact. In this space human and machines are not fighting each other for dominance but seeking to complement the role of the other. But this requires new skills and employee roles, a new understanding of team and management, and maybe even a new understanding of work. Personally, I think there is real potential here for social care to take the lead in creating workplaces where AI contributes to a reformed and developed role of the social carer. It is not a case of one or the other but both contributing. As I have often said, technology can enable human presence but it should never replace it.
Dougherty and Wilson argue the leading organisations are already riding the ‘third wave’ by adopting a MELDS Framework – comprising mindset, experimentation, leadership, data and skills. What might a MELDS Framework look like for social care in Scotland? We need to find out and engage in that discovery sooner rather than later.
Already there are an amazing group of highly innovative and entrepreneurial social care companies and technology developers trying to enable a new approach to care. The next few years will be critical for shaping that future as one with the person at the centre rather than the process. It is becoming time critical that we work together to shape person-led and person-centred models of technology in care. I am confident that we can achieve models of AI which are truly grounded in a human rights based approach to technology enabled care.
As part of that journey, Scottish Care is delighted to announce that we are hosting our first ever event dedicated to technology and social care. ‘Tech Care, Take Care.’ will be held on the 24th August at the University of Strathclyde Centre for Technology and Innovation. It’s an event which will bring together some of the best designers, technologists and innovators from across Scotland and further afield. But it is also an event where we will spend some time looking at how we develop an ethical, rights-based approach to technology and care in Scotland. We hope to publish on the day a study on the relationship between human rights and technology in social care. We will explore the contribution and also the limitations of AI amongst other areas of innovation. We will consider the personalisation of care from a technological perspective in this ‘missing middle.’
So the only sense in which the term ‘social care Luddites’ fits is in the desire to develop an ethical personalised approach to technological innovation rather than a desire for social care to break up the machine! It’s going to be an intriguing ‘third wave’ to ride, why don’t you join us?
Dr Donald Macaskill
We are just two days out from the annual Scottish Care, Care at Home and Housing Support Conference which will be held in Glasgow on Friday 18th May. If you haven’t already got your tickets there is still time to join us at what looks to be an intriguing and enjoyable day.
This year’s conference is entitled ‘Practical promise: making the vision of home care real.’
The word promise is an interesting one. In strict definitional terms a ‘promise’ is a ‘transaction between two persons where the first person undertakes in the future to render some service or gift to the second person’
What’s that got to do with care in someone’s home? – I would suggest everything.
At a very basic level the concept of promise is at the heart of the human exchange which good care and support offers. Every time an act of care takes place there is a service offered and a gift exchanged. Not a gift in the literal sense but the gift of support and person-led care which enables an individual to live their life to the full. At its heart that is what good home care is – it is an enabling process which offers an individual the prospect and ability to live as independently as possible for as long as possible.
All too often in some of the debates I take part in about the future of care and support in our community there is a presumption that care at home and housing support are about maintenance – keeping people safe and healthy. Of course, that is part of the story, but it is by no means the whole.
People who require to be supported in their own home require that support not just to keep healthy but to enable them to lead as fulfilling and as rewarding lives as possible. Life does not just stop with a diagnosis it moves to a different level. Affective, human-centred care at home and housing support is about providing the support to enable people to still dream their dreams, achieve their goals, and create their future. Homecare should never be seen as maintenance – it is always about the promise of a life still to be lived; good homecare is not about a set of tasks to be performed but enabling people through support to achieve their full potential, regardless of age.
The relationship of care is infused with promise at its very centre. It says that I as I support you and care for you, I will be here to make sure that you have a life which is as full and meaningful as possible; that you are not limited by your need of care or support, that you have contribution to make and abilities to share.
But there is also another sense to the word promise which will no doubt be reflected upon during our conference on Friday – and that is the degree to which a promise has a future orientation and perspective. Within the word promise there is a sense of hope, of expectation, of things yet to be achieved… a sense that things will be better and that new direction will be found.
The care at home and housing support sector is at a critical juncture in Scotland at the present time. We are living and working in extremely challenging financial environments, and with great uncertainty and fear for the sustainability of the care at home and housing support sector. But there needs to be promise.
With political conviction and appropriate financial investment, the future direction can indeed be one of promise. Rather than disintegration and paralysis. There simply has to be a future vision of homecare where grounded in the realities of day to day care-giving, we can create a social care system in Scotland which values the human rights of the individual, treats all with dignity and respect regardless of their chronological age, and which seeks to ensure that the individual person is in control not only of their care but of the direction in which they want their living and dying to move. There has to be a vision which gets us beyond the reckoning of support by segments of time for allotted tasks, which seeks to purchase that care at the cheapest price and pays lip service to the principles of choice, control and involvement of the supported person.
We all know what the ‘promise of care’ in the future needs to look like. It is a rooted, grounded practical vision of a Scottish society which cares and manifests that care not just in word but in action. The time is surely here for fulfilling that promise and building that vision into practical reality rather than uttering yet more pious platitudes.
That is the promise – a system which would make all of us who do the work of care and support rightly proud – a social responsibility for a nation. Join us as we continue creating that practical vision rooted in the promise of dignified support and care.
Dr Donald Macaskill
“Writing is easy. All you do is stare at a blank sheet of paper until drops of blood form on your forehead” – Gene Fowler
That is how I felt as I stared at the blank screen of my iPad!! A “blog” what is that!! I am too old to learn about these new-fangled methods of communicating!! I like to talk to people – how spooky is that in this digital world? I have been in the Care Sector for over 30 years and I have experienced, both professionally and personally, the highs and lows that we all face every day.
This Blog could be a “low” but I hope you will find it at least a “medium” . I am the Local Integration Lead for Perth and Kinross; not sure my mother would appreciate me being called a “LiL” as is the affectionate term for us all. As in every Partnership area we are striving to meet the challenge of supporting the Independent Sector in a period of change and continual pressure on resources. Despite these everyday issues there are still examples of good practice and successful initiatives that we can share.
P&K were successful in being selected to take part in the National Pressure Ulcer Project whose aim was to reduce pressure Ulcers in care homes by 50%. A pilot group of five care homes participated in the programme to test and evaluate documentation and processes that had been put in place initially. Valuable lessons were learnt in P&K and elsewhere during this pilot project. A celebration event in P&K was held in January where the care homes that had participated were asked to present their learning and experiences and share them with the wider care home group.
With the associated learning, such as the newly introduced pocket guide, the Pressure Ulcer Project is now being rolled out in care homes throughout P&K. The pocket guide, which came as a direct result of an idea from a care home in P&K has now been adopted nationally.
A new initiative in P&K is to support the Care Sector in the recruitment of Care at Home staff. We have always known that the recruitment and retention of staff is one of the Care Sectors’ major challenges. How do we demonstrate that the Sector can provide worthwhile training and a fulfilling career? We have recognised for many years that there is a high turnover of staff generally. Our challenge is to start replacing their knowledge and experience now. The joint initiative between the Local Authority and Care at Home Providers sets out to utilise the Modern Apprenticeship scheme in a way that benefits both the individuals and the sector. The Council will effectively be the managing agent and the staff will be seconded to the Care at Home service for a period of 18 months. During this time, they will undertake the SVQ Level 2 qualification and gain valuable practical experience, At the end of the 18 month programme the Apprentices will be offered a permanent position with the Care at Home Service. I am delighted to report that five Providers have signed up to the scheme.
Every now and again despite the challenges we all face attending endless meetings and discussions, and we have all been there!! My faith in the sector was restored recently, in terms of reinforcing why I feel so passionately about delivering excellent care. I sat in Perth Concert hall not listening to Andre Rieu, although that would be good as well, but at a conference organised by the Life Changes Trust listening to four enthralling individual stories of the demands and commitment faced by unpaid family carers. They all had different life histories, but the common thread was their wish to ensure their loved ones had the best support through the most difficult period of their lives. They talked about the basic day to day challenges they had to overcome and despite this they maintained a focus and commitment to continue supporting their loved ones.
It isn’t always about policies and procedures at the end of the day, it is about dealing with people in a caring and dignified manner. This was outlined brilliantly by Donald Macaskill in his opening address.
We must always ask the question: “Are we delivering the care and services that people actually want!”
Mother Teresa said:
“The most terrible poverty is loneliness, and the feeling of being unloved.”
Perhaps we should remember that unpaid carers can feel alone and unloved and how we interact with them as individuals and organisations can have a huge impact on their wellbeing.
Bereavement support is not an option
Professionally I have been involved in the work of bereavement for most of my adult life, both teaching and writing about the experience, not least for those who struggle to express their thoughts and feelings. In some senses I am at ease talking about death and dying, about the pain of loss and the emptiness which the absence of love leaves. You could say it has been my particular field of professional and academic interest.
At a personal level like so many I have had times when I have lost those close to me. I have been forced to do the hard work of grief on too many occasions and for too many moments. In those times I have struggled to find a path through and a sense of balance when the waves of absence overwhelm.
Bereavement is the sense of feeling robbed and bereft. For no matter how expected or anticipated a death or loss is, its ache is still sore, its pain still raw, its touch a cold beyond description.
This sense of lost-ness is beautifully conveyed in the original word for ‘bereavement’ from the Old English- ‘bereafian’ which denotes a sense of deprivation, of being robbed by someone, of being seized or grabbed out of living and life.
One of the reasons I wanted to write about bereavement is that at Scottish Care we have decided to make it a focus for some of our work this year. We have held useful and creative discussions with organisations like Cruse Scotland and colleagues in health and social care.
But in wider discussions on bereavement I am sadly detecting a resistance or a certain degree of apathy. It’s almost as if it’s okay to talk about palliative care and end of life, to develop a framework and priorities for those, but somehow bereavement is considered to be the concern and the preserve of the individual.
There seems to be an attitude that bereavement is a grief work which is not deserving of resourcing or strategic priority. I think this is both sad, mistaken and damaging.
We have loads of evidence to show that as a society in Scotland we have lost the cultural and societal ability to deal with dying and have misplaced our skills at working through loss in bereavement.
It is for that and many other reasons that we have solid research which shows that many doctors are struggling to cope with death and dying and are needing support to grieve and to do the work of bereavement.
For social care the Scottish Care report ‘The Trees that Bend in the wind’ last year spoke movingly of the way in which care staff whether in care homes or in the community in homecare services felt poorly equipped to deal with the continual losses they have to experience.
Bereavement support should be a central and critical priority for all who commission care and for all those who make strategic policy and practice decisions. To do other is to fail to support clinicians and carers at their point of real vulnerability and pain.
No matter how skilled and experienced you are we all need to be supported and upheld through our grieving, we all need to find a solace that comforts us in our weakness and binds us up when we feel broken.
When we have a sense of futility and despair, both personally and professionally, we need there to be space to open up and pour out our feelings; we need there to be people who have time and capacity simply to be present and there for us.
Good bereavement support is no optional extra, it is rather fundamental to a society basing its character on dignity and human rights. Good bereavement support renews and restores, it can give a sense of purpose and direction, for many it’s what has literally saved their lives.
I fear that if as a society in Scotland we fail to enable and resource those who do the work of care to grieve properly and to enrich them through good bereavement support then we are sowing the seeds of a harvest of regret and despair.
Dr Donald Macaskill
Prevention is the best care: the potential of prevention
In almost every strategy on health and social care in Scotland which you come across these days the two concepts of ‘prevention’ and ‘self-management’ are likely to appear somewhere. They are the aspirational essence of the modern health and care economy. Yet in reality for all the talk there has been little substance added to their mention.
In public health the mantra of prevention has been assiduously articulated. We know the success of preventative approaches in terms of smoking and the significant decline in diseases of the lung as a consequence. We also consciously recognise the benefits of anti-obesity campaigns and attempts to limit sugar intake even if we don’t always follow them. But in the realm of social care ‘prevention’ is often a political and policy mantra which carries little meaning and certainly not one which is currently deserving of resource commitment.
Last year Becca Gatherum in her report for Scottish Care, Bringing Home Care,articulated a vision of care at home which was firmly grounded in the principle of preventative approaches, was rooted in robust research including that of the LifeCurve and which evidenced real individual and societal benefit.
So what do we mean by prevention in social care? Put simply they are those models and approaches which prevent an individual from either early or unnecessary access to enhanced care, hospitalisation or sharper personal physical decline and deterioration. They are approaches which enable independent living for a longer period of time and are focussed on maintaining a higher quality of life and wellbeing. They are about maximising autonomy and control. And yes, significantly they are not only about personal benefit but providing an economic and societal benefit through the avoidance of expensive clinical and especially surgical intervention. Falls prevention is perhaps the best exemplar of the promise and potential of preventative social care.
Yet nearly a year on from the Scottish Care report I see no evidence of any Integrated Joint Board robustly taking up the vision of preventative care. Well strictly speaking that might not be true. There is ‘talk’ of prevention and there are some attempts to use technology enabled care to initiate some developments. Such approaches which use technology to map and monitor decline and physical change in a person have real benefit but without being part of a bigger prevention strategy they can only go part of the way.
In fact it might even be that we are causing damage to truly effective preventative models by some of our proposals and plans. I have seen in recent weeks some horrendous proposals appearing before IJBs which predicate savings based on reducing care home provision on the basis of using technology and assuming a non-existent robust and coherent homecare system which is enabled to undertake even more advanced clinical support in the community. This is dangerous thinking not deserving even of the mirage of planning and threatens not only individual harm but also any serious attempt to systematically reform the health and social care system.
A holistic model of preventative social care maximises the benefits of technology rather than uses it to replace human presence, professional judgement and instinctive experience.
Yet maybe it is not surprising that we have failed to see the adequate resourcing of preventative approaches – because they are initially costly and because you cannot remove advanced homecare at the same time.
Surely the time has come for us to not only to talk the talk around prevention but to be brave and start to walk the talk? It is time for someone somewhere to invest substantially in a model of preventative homecare AT THE SAME TIME as maintaining and building enhanced homecare. They are reciprocal and inter-dependent processes. The one cannot exist without the other. Prevention cannot be used as a replacement for person-led, rights-based, dignified care. You cannot achieve the beneficial outcomes of preventative approaches without initial investment – just ask any public health specialist!
Social care in Scotland urgently needs a sense of political vision which goes beyond bandaging the present system and dares to heed its own mantras and invests in real preventative social care.
Dr Donald Macaskill