How many of the changes in NHS practice will continue after this crisis is over? (3)

…and Social Care?

My two previous posts this week have congratulated the NHS for the rapidity of the changes it has brought in to both remote primary care and the skill mix.The issue now is whether these changes will continue after the emergency.

Today’s post concerns social care and its relationships with the NHS.

Whilst the crisis has created a necessary transformation in primary care and in the application of skills in the NHS, it has not transformed the relationship between the NHS and social care.

“Decades of wider policy direction for social care has created a very fragile service.

Mostly this is not the fault of the NHS. Decades of wider policy direction for social care has created a very fragile service. It has little organised resilience to face a crisis.Let me explain why.

The provision of most residential care is now owned by companies who are in turn in debt to hedge funds. The amount of money paid by most local authorities for a place in residential care does not cover its cost. This fragile economic model only works because they are subsidised by the self-payers who pay higher prices. That requires homes to have a large number of beds to be viable. The economics of the situation creates large homes where self-isolation is impossible.

Many very vulnerable people are collected in one location. The sector is fragile.

In domiciliary care the situation is worse. Major providers have exited the market and there is no prospect of a resurgence. The sector is fragile.

Across both sectors many staff are paid the minimum wage and are given little training. When a new hypermarket opens in an area bringing new demands for labour, the shortfall of staff in that locality’s social care increases. The government’s new immigration policy (still scheduled to become law next January) sees social care workers as unskilled and will effectively ban migrant care workers from coming into this country.

Shortages have led to a necessary use of agency staff who keep homes going by moving from home to home. (Think about how that works that in an infection crisis..).

All of this means that in no real sense of the word is there a social care “system”. The NHS is a system. (It may creak a bit; fall out with itself – but compared to social care it is undoubtedly a system).

Given its importance, the failure of our society to create a powerful system of social care will, in future years, puzzle historians. But now, within this crisis, I understand why, on April 4, the Daily Mail had 4 pages outlining the “Catastrophe in Care Homes”.

Over the past 5 years (and longer in many parts) in much of the country the NHS and social care have tried hard to build better relationships. Nearly everybody who receives social care also receives NHS services – so the relationship between the sectors in terms of the shared experience of the people who receive services is very strong.

A few places have done this well. But if you look at the 20+ CQC local area reviews that looked at how the NHS and social care worked together for people over 65, you will find very few areas that have created genuine person-centred, coordinated care.

And when a major infection crisis comes along this fragile structure receives such a hard knock that we can see it really fall apart.

First, it isn’t really surprising that, in terms of the impact of the virus on their lives, most people receiving social care are also amongst the most vulnerable in society. They are the most likely to die if they catch the virus.

In residential care there can be no self-isolation. Trying to isolate 75 residents and 50 staff is not quite the same challenge as it is in a family home. Staff working with residents may be agency staff visiting several homes a week. It’s as if we have created a form of service specifically designed to maximise infections.

In domiciliary care the model we have depends upon individual staff going from client to client carrying out their duties, many of which involve intimate services. They will care for many different, vulnerable people every day. If the care worker doesn’t turn up their clients may not be toileted, get out of bed or eat. But if they do turn up staff and clients are, by definition, doing the very opposite of isolating. With staff that may be ill moving from household to household and making bodily contact, the chances of spreading infection are high.

Given its status as a national service, the NHS has found it very hard to relate to the very fragmented non-system of social care. For those receiving social care this difficult relationship between their social and health care has always been significant. With the virus emergency it becomes a matter of national importance.

If people within a residential home get the virus, the chances of their dying are high. If the contagion cannot be contained, the chances of a large number of people dying are high.

So stopping the infection in the first place looks critical. But the failure to provide enough tests for the NHS means that there have been very few for social care staff and people. The same is true for PPE.

Let’s not forget that the name of the Department of State is the Department of Health and Social Care and let’s also remember how that service – added on to the end – has been left out.

At end of this crisis a lot must change. Social care will have to be transformed.