My late mother used to say that the seasons changed when the schools went back. With the passage of time, I have come to realise the truthfulness of such observation rather than to dismiss it as I once did as the fruit of Highland pessimism. As Scotland’s schools have returned or are just about to, the seasons do indeed seem to be changing. The days are getting shorter, the summer bedding plants are dying back, and there is a slowing of nature as it begins to get ready and prepared for colder times.
It is therefore maybe not surprising that next week along with colleagues from across health and social care I will be attending a workshop session to explore winter preparedness. Last year was a very challenging time for many who worked in, delivered and importantly those who used social care and health services. So, it is very necessary for planning and preparation to take place early in our autumn. But just how ready are we for the weeks and months that lie ahead? I want to reflect in this blog, briefly, on where we are at in the world of social care in Scotland as we start to move towards the winter.
Covid 19.
To all intents and purposes, for the vast majority of the public in Scotland Covid has disappeared from both thought and consciousness over the last few months. Its fear and hold have been burnt back by the summer sun. Indeed, at the end of the month the current practices around testing of health and social care staff will stop altogether unless someone is being discharged from a hospital into a care home. Though there is a rider that testing will happen for individuals if there is a clinical need.
But of course, for those of us working in social care Covid has never disappeared. It is still here and the casual dismissal of its impact by some ill serves those for whom its impact remains significant. There are countless thousands of Scots who are immune suppressed and who are struggling to lead ‘new normal’ lives because of their fear of catching a potentially damaging virus if they interact with a society where protections and mitigations are minimal. Indeed, for those individuals the very dismissal and denigration of their desire to protect themselves has made themselves even more fearful of social exchange.
In addition, there are tens of thousands of our fellow citizens for whom Covid has had a lasting potentially life-long impact because they are living with the consequences of Long Covid. I cannot imagine there is anyone out there who does not know someone living with Long Covid. And for those who simply and dismissively say catching Covid is just like getting the flu (though when did getting the flu become such a casual happenstance) then I would ask when did you hear of tens of thousands with ‘Long Flu’ or permanent damage from the flu affecting thousands? Indeed, the negative impacts of frequent infections of Covid are increasingly being researched with not a little scientific and clinical concern in some early studies. Covid is not ‘just’ the flu by any stretch of any imagination.
As we move into autumn this last week there has been a much increased media coverage about whether or not there has been a growth in Covid cases over the last period and whether this is something we should be concerned about. In truth this is hard to determine when there is no real community surveillance, but we do know that the World Health Organisation continues to identify new variants. One such is EG5 or Eris and even more recently BA2.86 which was identified first in Israel just last week and is already causing some anxiety as to its rapidity of spread. Not surprisingly new variants will keep coming. What is important is whether they will escape the vaccine and community protection which the majority have at the moment. The BBC related the levels of Covid in a good piece this past week in Should we be worried about Covid this winter? – BBC News .
But anecdotally I am coming across many more friends, family and colleagues who have Covid or have recently had it. (If only we had decent community tracking!). The data we do have is mixed but does seem to show an upward trend which is a concern given that this is early August. Data reported on the 17th August on the Public Health Scotland database indicated that there were 183 people admitted to hospital described as acute Covid admissions. This was up from 139 the week before. This meant that there were 219 people in hospital with Covid19 on the 13th of August compared to 166 the week before. According to data from National Records of Scotland reported on 17th August there were 17 deaths involving COVID-19 in the preceding week (to the 13th). This is an increase on previous weeks. The Care Inspectorate reported that in terms of the number of Covid outbreaks in the week to the 15th August there were 39 care homes which was 17 more than the previous week and is 4% of all homes reporting. This is a 3% increase in a fortnight, and I hope is not a developing trend but anecdotally one is hearing of more staff off ill with Covid which is also reflected in their data stating that for the care homes which reported to the week ending the 15th August with Covid here were 108 staff absent which is 0.3% of the workforce from those 60% of homes which reported. A fortnight before this was 47 staff – so a doubling in absence rates.
As someone who looks at this data on a weekly basis there is clearly an impact from new variants and what appears increased transmission. It makes the roll out of the winter vaccination programme all the more critical for all who are eligible. What I think is a concern is the potential impact of a bad flu season on top of Covid19. Last winter we avoided a bad flu impact in part because of a more effective vaccine.
So even if we are able to step up our Covid and respiratory response there is likely to be a continued pressure on a health system which is already under strain and on a social care system and workforce which is in a worrying state.
Workforce
The health and morale of our workforce is a key issue for winter preparedness. Obviously, absence due to Covid is a matter of concern for any person working in social care. But we are already in a situation where the workforce in social care is, I would contend, at its lowest ebb. I will not rehearse again the immense disappointment felt by frontline workers and organisations around the failure of the current Scottish Government to come good on their promise to pay frontline staff £12 an hour. We still do not have an indication of a timeframe for this despite the promise being made in the spring. What has happened since is what we all knew would happen and that is a haemorrhaging of frontline care staff from independent and third sector organisations into both better paid public organisations and the NHS, and even more worryingly out of the health and care sectors in entirety. Like many I was pleased with the news of a few days ago that our junior doctors had settled their dispute, but even this news makes frontline social care staff feel yet another kick in the teeth. What must happen for the promise of increased remuneration to become more than a political soundbite and instead to be a promise fulfilled?
Last year was very challenging for the organisations I know whether care homes or homecare providers, regardless of them being charitable or private. It was very hard to hold onto staff and even harder to recruit in such a high employment and competitive environment. With the fact that NHS colleagues are now getting paid so much more than social care it will be harder still. The gaps were plugged at huge cost last winter using agency staff, but even agencies are struggling to recruit.
But more than the issue of pay is the issue of regard and value. I have lost count of the demoralising conversations I have held over the summer with frontline care staff who simply do not feel valued. We are a lifetime away from claps on a Covid Thursday night.
Sustainable services
Alongside a demoralised workforce social care provision in Scotland has never faced the extent of financial instability it is now enduring. Given that in Scotland so much provision is delivered by smaller organisations this has left them susceptible to very real risks not least because of the ongoing cost of living crisis and the lack of external and public investment in care and support. I have a very real concern that to keep their heads above the water and because of a lack of frontline staff that social care providers, whether care homes or homecare organisations, if called upon to increase capacity and response in the weeks and months to come, have done previously.
We are already witnessing a level of care home closure and a reduction in bed availability the like of which no one I talk to can remember. More and more care homes, if they can, are making the decision not to admit residents funded by the National Care Home Contract because it is simply not sustainable. In terms of homecare more and more hours are being handed back because they organisations cannot afford to deliver them at what they are being paid. More recently the level of late payments and cash-flow issues are having a profound impact on small homecare organisations. Social care is a sector whose fiscal fragility should send alarm bells ringing.
Whole system thinking.
What matters most to people at any time of the year not just winter is that they remain at the centre of all our planning and preparedness in the weeks ahead. The challenge of these days is not about numbers and statistics, but about what the experience of every individual is. I have written many times in this blog that getting through a winter (or any season) is not ‘just’ about delayed discharge, or making sure that the acute sector hospital flow is operating well, or even discharging people to be supported in their own home through models like hospital at home. It is all that, of course, but it is also critically about preventative care and support; intervention upstream that delays decline and enables people to remain independent for as long as possible. Too much of our focus (both in terms of media and politics) is on one part of the health and social care system at the cost of the whole. Investment in social care and homecare in particular would massively re-right that imbalance.
In general terms then I am very concerned about the capacity of an already stretched system in health and social care to respond to whatever the winter brings us. If we use the obsessive media metric of delayed discharge our numbers are very high for the time of year. According to the latest published data at June 2023 census, 1,738 people were delayed. The high point of November 2022 was 1,977 people delayed. Our hospitals are working at levels which after such a long period of maximum occupancy are exhaustive.
The risks of the following season are clear from rising Covid and other respiratory conditions, a tired, exhausted and devalued social care workforce, a failure to invest in the social care system as a whole, and in my viewpoint a myopic focus on one part of the system rather than the whole. This is all made worse by the stripping of funding and support from many communities and third sector organisations which has left our neighbourhoods ill prepared to support their citizens. Added to this the immense pressure placed upon the army of unpaid and family carers over the last few years has led many to the brink of being unable to continue and this is not helped by the voids and gaps in respite day support and opportunities.
There is, however, no shortage of talented committed individuals across the whole of Scotland willing to make the difference, working hard to get things right. There are plenty of innovative ideas which are being put into practice and implemented across the country to make sure that the experience of citizens is as positive as it can be and literally that lives are saved and enhanced. We all know planning is critical but planning only works with honest appraisal of the environment around you and if the adequate tools and resources are made available in order to get the job done. Planning only works if the analysis (which most agree on) and the solutions and interventions (around which there is much agreement) are enacted upon. I hope by working together rather than in siloes we will not only get through these coming weeks but thrive but all of that doesn’t just depend on collaboration, critical through it is to have everyone pulling in the one direction, it also depends on political and societal leadership and making hard fiscal decisions which for me means starting to prioritise social care. If we get social care right this autumn we will all get through the winter.
Donald Macaskill
Photo by Aaron Burden on Unsplash
