“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

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