Finding a way through – achieving a balance between risk and protection

Finding a way through – achieving a balance between risk and protection.


It is now over eight weeks since Scotland’s care homes went into lockdown. Overnight they changed from places of busy interaction and banter, entertainment and encounter, into environments living under strict infection control and with limited interaction with the outside world. They became quieter places, with people no longer sharing common spaces, meeting up with friends, having a laugh with neighbours, gossiping has given way to silence. Care home staff have tried their hardest to keep life going as close to normal as possible, to give special attention to those who need it, to support through encouraging smile and contact, to encourage and even to entertain. Technology has been used well to maintain contact and to keep connection going but there are many who cannot use it or don’t understand how to.

Frontline staff in many care homes have fought tirelessly to keep the pandemic at bay and through their skill and dedication have nursed many hundreds back to health despite Covid. But as this week yet again bears testimony they have also lost to the virus many people who have died before their time.

Despite all the hard work of staff, care homes are living in a twilight zone, a place of unreality and a place of real discomfort.

I have written before about the aching sadness felt by families who feel that they are slowly losing a grip on the lives of loved ones who are slipping away from memory with each passing day. I have spoken about the tears that are felt as significant birthdays pass by with only a knock on a window or a wave through an iPad by way of family celebration. I have affirmed the importance of being present at the end of life to say goodbye.

At the start of the pandemic the strict infection control measures introduced included a reduction in foot-fall into care homes with an aim of reducing that by 75% to all but ‘essential visits.’  Through time we have seen enhanced measures for PPE, improved testing regimes, stricter admission criteria and now in the latest Guidance published last night, a much greater appreciation of the impact of all these measures on the lives of people with dementia. Over time I think we will come to appreciate that infection control protocols which work in a clinical institutional environment like an acute hospital or unit need to be adapted much more sensitively to fit a place which is primarily someone’s home, where people are not patients and the environment is non-clinical. I am personally very clear that the area where there needs to be much more appreciation and adaptation of infection practice is in the realm of human contact – especially for the vast majority of care home residents  (perhaps as many as 90%)  who live with some form of dementia.

At the start of the pandemic I wrote to a few folks who questioned the appropriateness of some of the early strict exclusion measures and who voiced concern at the impact on the human rights of those involved. My argument at the time was that the measures were appropriate in that they were a proportionate response to achieve a legitimate aim which was the preservation of life. Now that we are eight weeks into those measures and after countless emails, messages and conversations with families and with some residents, I think we all collectively need to reflect on whether our restrictive measures are enabling us to  continue to uphold the human rights of residents and their families, or whether we need urgently to review some of our measures and to adopt more flexibility.

What may have been a proportionate restriction at the start of a crisis and considered acceptable action for a period of time may no longer be appropriate months into the pandemic. I am couching what I am saying very carefully in questions because I do not think we are in the territory of hard and fast answers but in a place where we need to nudge and feel our way forward to solutions.

I think we all of us need to find our way through to a better way of being and living especially for individuals with dementia in our care homes. I am not convinced the current processes are sustainable or remain justifiable. John put the dilemma to me quite clearly – he is nearly 100 with months to live by any calculation, and he wants to spend that time not ‘imprisoned in his room’ (his words) but being with his family even if at a distance. Quality of life matters more for him than quantity of life. He said to me “It is my human right to decide to take the risk!”

For perhaps the overarching concern in all the correspondence I get is the loss of connection and relationship felt by individual residents and their families. No matter how attentive and creative care home staff are there is simply no substitute for physical interaction with family.

The current Guidance rightly states that in situations of ‘distress’ that it is important that families of people with dementia and learning disabilities are allowed contact under strict criteria. Over the weeks it has become clear to me that such distress is not just seen in behaviour which becomes angry, frustrated and challenging but in what I have called a ‘quietism’ where the person withdraws into their skin and self, where they turn their face to the wall despite all the positive measures around them, where they have started to dis-engage and switch off – because connection with those who matter is not there. Many individuals with dementia even if they do not remember the name of loved ones intuitively know they are connected, that they are part of another, related and linked, loved and wanted.

We all of us collectively need to find a better balance between individuals knowing the risk, the requirements to wear PPE, the importance of encounter and the desire to prevent infection at all costs.  But when I speak to care home managers and staff, especially in care homes where there has been no infection, they are terrified that enabling people to re-connect risks putting others at danger. They are also after days of external blame and finger-pointing at the care home sector, terrified of becoming the object of scapegoating if something were to go wrong after they allowed a family member to visit. I think we urgently as a whole society from politician to media, from commentators to citizen, need to empower our care home staff and providers to feel they have the confidence to re-connect people with one another.

And there are ways of doing this. People have spoken of getting permission to have a family member escorted into the building following defined footways and of bringing together individuals at a safe distance in an outside space. Hearing of these ‘reunions’ and the comfort they have brought has been very moving indeed. But we need to do more. For instance, we need to explore the use of testing as a way of connecting people up to their household ‘bubbles’.

It feels really uncomfortable as the rest of the world becomes fixated on ending lockdown that there is a presumption that in care homes this unreal form of existence and dis-connection will go on for much longer. We must, I believe, give trust to professional care staff to find new ways – safe ways – to connect family.

Scottish Care has established a clinical care group which over the last two weeks has been  actively exploring how we can work better in this area and develop models and approaches to get the balance right and to better restore the human rights and choices of residents. But it needs the rest of society to embed trust, give confidence, and permission to the care home sector to restore relationships. We urgently need to find a way through from where we are which is no longer tenable to something resembling human connection, with families being together and re-united with residents in compassion and love.

Donald Macaskill 

Last Updated on 1st June 2020 by Shanice