Learning lessons and looking forwards – new Scottish publications impacting long-term care policy

Jenni Burton (Clinical Lecturer, Academic Geriatric Medicine, University of Glasgow, @JenniKBurton)

August 2021 was an important month for long-term care in Scotland with the publication of two reports. Although these focus on the pandemic response and future care service needs in Scotland, there are aspects which may be of interest across the LTCcovid community. In the interests of transparency, I have not had any direct involvement in their production, these are Scottish Government publications, shared for wider interest with some personal reflections on their content. 

The first report ‘Lessons Identified from the initial health and social care response to COVID-19 in Scotland’ is based on the period March to September 2020 (essentially the first wave of pandemic and initial recovery phase in Scotland, critically before the second wave of infections and before the advent of vaccination). It is based on a synthesis of documents, engagement with senior leaders and stakeholder engagement coupled with international case studies sought to inform the Scottish pandemic response. It provides multiple recommendations and priority actions across the whole of the health and care system. However, there is a specific social care section whose primary focus is on care homes. 

There are some very honest reflections in this report and open acknowledgment of the real challenges which impaired the effectiveness of the initial response. For example, it acknowledges the relative lack of social care expertise within Scottish Government, particularly around care homes, and the reliance on a small team of informed individuals. While new groups have been formed to draw on a wider pool of expertise, the recognition of the need for context-specific expertise at the heart of government is critical. 

The report acknowledges communication challenges, particularly around publication of guidance and updates to existing guidance. A specific issue is the recurrent practice of sharing changes to guidance at the end of the working week, often late on Fridays and the negative impact this has. It makes it more difficult for staff to respond in a timely way, it makes the work particularly of care home managers harder as the expectation is that they will read, synthesise, and implement immediately. Where guidance applies to NHS settings, there are delays in sharing of information with clinical teams which results in further disconnections between guidance and practice with distressing impacts on the individual’s guidance is designed to support. This is an issue which must be resolved, particularly as the pandemic continues, we must be respectful of the professionalism of all groups and provide realistic time for providers to synthesise and implement guidance. Important also to make real the commitments around supporting staff wellbeing, that weekends and non-working hours are respected out with truly emergent situations. 

The report openly acknowledges the experience of staff working in social care: 

“the Social Care workforce felt undervalued and underrecognized prior to the pandemic, and that there were reports of similar feelings during the early response……. but there is a deeper underlying sense that Social Care workers have not had parity of esteem with their NHS counterparts….”

This sense of disparity is also evident around the impact of the Lord Advocate’s investigation into deaths in care homes, which is being undertaken by Police Scotland. The report states: 

“While acknowledging the need to assess what went wrong, participants expressed that this approach was substantially increasing the very high levels of anxiety being experienced by professional, skilled staff who support and care for the most frail and vulnerable people in our society and there is a perceived and felt search for blame”

At the time of writing, we await the findings of this review, which has seen the police attend care homes where an individual has died because of COVID-19 to investigate. As a doctor working in hospitals, where we know across the system individuals have contracted nosocomial COVID, I can only imagine the trauma and impact on staff members on being questioned around the care they have provided to the residents they support and care for. The voices of those working in Scotland’s care homes during the pandemic has not been heard and there is an opportunity for sensitive qualitative research to explore their unique perspectives and experiences to inform understanding and practice.  

Positive aspects of the report are around the recognition of the importance of care homes and seeing them as part of the whole system of care. This must be done mindful of their context as individuals’ homes. There have been improvements in collaborative working and opportunities for connecting care home residents with specialist teams is a promising development which requires further infrastructure to support it. Progress and developments around data and digital capacity have led to the publication of a Digital Approaches in Care Homes Action Plan which openly discusses the disparities in connectivity across the system and need for improvements to work towards truly digitally enabled care homes. 

A particular interest of mine is around data to support our understanding of the needs of those living and working in care homes, a topic discussed in an earlier LTCcovid blog (The invisibility of the UK care home population). Therefore it was welcome that the need for improved data is specifically acknowledged, although the framing of this currently is around ‘understanding capacity and use of the sector’, where what is needed is intelligence to allow us to support the individuals concerned more effectively, evidencing their needs and the impact on outcomes.  

The second publication A National Care Service for Scotland – Consultation has been produced in response to the Independent Review into Adult Social Care, undertaken by Derek Feeley, published in February 2021. The review was commissioned because of the visibility that the pandemic afforded to the existing challenges faced by the social care sector and those who work within it and draw on social care support. The review was clear in articulating a vision of social care: 

“Strong and effective social care support is foundational to the flourishing of everyone in Scotland. It is a good investment in our economy and in our citizens………We need to shift the paradigm of social care support to one underpinned by a human rights-based approach.” 

The review advocated strengthening existing foundations and a redesign of the system, including development of a National Care Service. However, it also recommended that this new system must be co-produced with those it is designed to support. 

The consultation document is the Scottish Government response and its ambitions and undertakings to enact the findings of the review. In total, there are 96 consultation questions around the themes of: Improving care for people, National Care Service (and scope), Commissioning, Regulation and Valuing people who work in social care. It is diverse in scope and radical in the scale of proposed changes it encompasses. It is welcome to see more accessible formats, including an Easy Read and BSL version, provided to enable participation.   

Data rightly features under the improving care for people theme, with questions around: nationally consistent, integrated and accessible electronic social care and health records, data sharing and whether legislation should be used to require care services and others to provide data as specified by the National Care Service, meeting common data standards and definitions. These statements of positive intent contain within them some complex and costly proposals, which should not be under-estimated. These have the potential to improve the delivery of care and support and evidence of impact. However, the motivation behind improved national data collection must be resolutely focused on improvement for those living and working in care homes, requiring data systems to measure what really matters to them and not just relying on what can more readily be measured.  

References to publications

Lessons Identified from the initial Health and Social Care Response to COVID-19 In Scotland. Available from: https://www.gov.scot/publications/lessons-identified-initial-health-social-care-response-covid-19-scotland

Connecting People Connecting Services Digital Approaches in Care Homes Action Plan. Available from: https://tec.scot/sites/default/files/2021-06/Digital-Approches-in-Care-Homes-Action-Plan-Final.pdf

The invisibility of the UK care home population – UK care homes and a minimum dataset. Available from: https://ltccovid.org/2020/05/14/the-invisibility-of-the-uk-care-home-population-uk-care-homes-and-a-minimum-dataset/

A National Care Service for Scotland Consultation. Available from: https://www.gov.scot/publications/national-care-service-scotland-consultation/

Adult social care: independent review. Available from: https://www.gov.scot/publications/independent-review-adult-social-care-scotland/

A National Care Service for Scotland Consultation – Easy Read. Available from: https://www.gov.scot/publications/national-care-service-scotland-consultation-easy-read/documents/

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