Keeping care at home: time to invest in preventative social care and support.

Yesterday was the Scottish Care, Care at Home and Housing Support conference which was held in Glasgow with the theme ‘Keeping Care at Home’. It was followed by an evening Awards ceremony in which participants were able to thank the amazing women and men who have worked in homecare across the country over the last year.

The day was one which was both inspiring and also concerning because so many of the conversations I held with those who were attending underlined in the strongest terms the degree of crisis and challenge which is being faced by the homecare sector across Scotland.

Politically and societally, there is a lot of agreement about homecare. People know that should their health deteriorate and decline, should the passage of time mean that they are less able and fit than they once were, then the place they would want to be is in their own home. The familiarity of place is critical to the psychological and emotional health we all know to be fundamental to our wellbeing.

There is also a generally accepted recognition that one of the ways in which we can help people avoid unnecessary admission to hospital is to keep them healthy and well at home. This not only prevents avoidable hospital admissions with all the pressures that brings on the whole health and social care system but more importantly with all the risks that being in hospital for periods of time brings to the individual themselves.

Over the last few weeks and winter/spring months there has been a great deal of media and political focus on delayed discharge – that is when people are unnecessarily delayed in being discharged from hospital when they are fit for discharge. There has been equal focus and attention – and indeed resource – being allocated to ‘hospital at home’ models and innovations. All of these are to be applauded and affirmed because they adhere to the great principles of the NHS, which is to treat, care and support individuals as close to home and community as possible.

But what about preventative social care? It is all very well to develop important initiatives to get people out of hospital and to support them in their own homes when they are discharged, but it would be so much better if we prevented or at least delayed for as long as possible admission into hospital. That is where social care systems and supports when they work well are able to make such a significant contribution.

One of the really negative impacts of austerity and the increasing resource swallowed up by the acute NHS systems has been the stripping out of the preventative approach, systems and models in social care. This has been a dangerous and damaging error. The less we spend on preventative social care the more we end up spending on the acute and secondary NHS.

Preventative social care comes in many guises. It is first and foremost relationship based social care where the support worker or carer is able over time to form a meaningful relationship with the supported person. Such a depth relationship – which requires continuity of staffing and consistency of service – build not only a relationship but critically enables the worker to develop the insights, knowledge and awareness that enables him or her to be aware of changes in the behaviour, presentation and health of the supported person. Without being overly idealistic – this is what good old-fashioned relationship-based care at home used to deliver as routine. Care staff knew their clients and were the early warning systems which recognised a negative response to new medication, which questioned the benefits of multiple drugs, which enabled a person to be independent rather than nurture dependency, which reduced the harms of loneliness and isolation, which monitored incidents such as falls, memory loss and deterioration and so much more.

Such good and effective preventative social care requires many things – not least of which is a staffing cohort which are valued, rewarded appropriately for their skills, and esteemed as core professionals and colleagues by others in a primary or community acre team. Their word, judgement and awareness are heard and respected.

But it also requires that most elusive of care and clinical tools – time. The sad increase in 15-minute care packages and visits over the last few years – at a time when we were supposed to be ending them – has had a deep impact on the quality of time staff are able to spend with individuals. I defy anyone to justify that such time slots offer dignified, right-based, relationship-focussed social care. They are transactions of function rather than timeslots of compassionate care and support.

There is another element to preventative social care which is often forgotten. Prevention of negative health incidents and decline requires an individual to self-manage a long-term condition or to be at the very least aware of the factors that might impact them in a negative way. Preventative social care can encourage folks to be more proactive and knowledgeable about their health and wellbeing. I think we are missing a great public health opportunity by not enabling social care staff to be the frontline of such public education, awareness, and promotion of self-management. If they have a relationship with the supported person, it is already a door open to increased awareness and communication. Good preventative social care which utilises the contact between carer and supported person could significantly lead to increased independence and thus reduce or delay the need for care and support services.

But prevention does not just happen – it is not an accidental by-product but something which has to be designed, nurtured, and resourced. I would love to see equal resource and emphasis being placed on investment in social care especially care at home and housing support being seen as a preventative tool as equally important as the resource we allocate to getting people out of hospital or caring from them clinically in their own home. But of course, that requires whole system, holistic health and social care thinking and co-ordination rather than just attending to one part of the system.

Donald Macaskill