Care crisis: Is it time to reform care sector in Scotland - and if so, how?

In the nine months since the pandemic took off in Scotland, 11,824 care home residents have died - 24 per cent more than in an average year.

Lessons appear to have been learned from the controversies over PPE shortages and the transfer of untested - and even Covid positive - hospital patients into care homes during the first wave, but the overall experience has triggered calls for a wider rethink of what social care in Scotland should be, how we deliver it, and maybe even how we fund it.

In September the Scottish Government commissioned an independent review of adult social care, which is due to report back in January.

“At its best, social care is about prevention,” said Dr Macaskill.

“What we’ve done for the past 25 years is essentially to strip out prevention from social care, and that’s been a huge folly because it’s resulted in people reaching a stage in their life of decline far sooner than they needed to.”

Dr Donald Macaskill, chief executive of Scottish Care

Ironically, he considers that part of our current predicament can be traced back to the introduction of Free Personal Care in 2002 - a flagship policy for the then Labour-Lib Dem led Scottish Government.

“At the point where we introduced free personal care, 67% of home care in Scotland was directed broadly to preventative care. It was shopping being done for people, their house being cleaned.

“It was low level support, but critically what that enabled was a relationship where the worker could spot areas of decline, get pharmaceutical intervention, get the GP involved, get community support for someone who might be lonely and isolated.

“When you strip that out - and it’s been worsened by austerity - we now have eligibility criteria. So to be eligible for social care you virtually have to be among the walking dead, the levels of eligibility for support are so high.

“We therefore stopped that preventative approach and it’s made it so much more challenging, so now - having been at 67% - we’re now as low as 3% in terms of that non-direct personal care being delivered to people in their own homes.

"That’s been an unintended consequence of what was supposed to be a policy introducing equality, but if anything it’s made it worse.”

READ MORE: Now is the right time to rethink what we want from a care sector

Dr Macaskill says that any shift towards a ‘National Care Service’ - whatever that means in practice - must include “a robust economic analysis of how we’re going to pay for social care”.

“If you call something a National Care Service you still need to resource it. We’ve got to ask some really difficult questions: how are we going to pay for this? Are we going to have personal insurance, are we going to increase taxation, is it going to be a mixed model?

“How are we going to stop the iniquity that somebody who develops cancer has most of their care paid for them but if you develop dementia you have to sell your house?”

The idea of a National Care Service might conjure up images of social care version of the NHS, but such a move would be exorbitantly expensive.

It cost taxpayers £900,000 to transfer ownership of Home Farm care home on Skye from HC-One to NHS Highland - could the Scottish Government really countenance nationalising all 614 privately-run care homes for older people in Scotland?

The independent review’s own minutes hint at something less radical, with discussions of how to achieve “consistency” in relation to pay rates, sick pay, pensions and time off for study between the independent, public and not-for-profit employers within the sector.

READ MORE: Mutant Covid strains mean we must rethink how we do lockdown in the UK

The evaluation also appears to be looking to international examples for inspiration on how to reform.

The review panel includes Göran Henriks, who has led an acclaimed transformation of healthcare in Sweden’s devolved Jönköping region, which has considerable autonomy and tax-raising powers.

The model is focused on integrated and preventative care for older people, and has been praised as “obsessively patient-focused”.

The views and experiences of patients (known as ‘Esthers’) on how to improve services are actively sought by healthcare teams at informal Esther ‘learning cafes’, and patients or their representatives make up a quarter of improvement project teams.

Göran Henriks

There are also ‘Esther home teams’ dedicated to helping patients settle back into their homes after hospital treatment to reduce the risk of readmission.

The system has delivered a dramatic reduction in acute hospital beds, waiting times to see a specialist, and the number of patients living in care homes, while the numbers living at home with medical care has doubled.

Another example scrutinised by the review team is the pioneering Dutch ‘Buurtzorg’ model, founded in 2007, whose motto is “humanity over bureaucracy”. The system , already piloted in Aberdeen, revolutionised community care in the Netherlands by empowering nurses to deliver all the care their patients need - from washing to wound care.

Under the initiative, nurses form neighbourhood-focused teams where they build up a caseload of patients and link up with local GPs and other healthcare professionals, such as physiotherapists or podiatrists.

Nurses must spend 61% of their time in direct contact with their patients, but are free to scale up or down the time the spend with particular patients whenever they need more or less attention.

An evaluation by KPMG found that the Buurtzorg approach was costlier on an hourly basis than other systems, but its highly integrated, flexible and prevention-focused style meant that it was significantly more efficient - so much so that there was a 50% reduction in the hours of care required on average per patient. Quality of care and job satisfaction among nurses also improved.

READ MORE: Women dying at home with dementia up 75% in pandemic

Another aspect being looked at by the review team is the possibility of “market oversight”, and questions about how that might be regulated.

At present, weekly fees for self-funded elderly residents in care homes who require nursing care range from £782 in North Ayrshire to £1,203 in Aberdeen.

Across Scotland as a whole, these charges have increased 54% in a decade - faster than inflation - and only those with £17,000 or less in assets, such as savings or property, have their fees covered.

Professor June Andrews

Perhaps because of the UK's strong attachment to the free-at-the-point-of-delivery NHS model for healthcare, we find the linkup between social care, private enterprise and profit unpalatable.

But as Professor June Andrews, a nurse and world-respected expert in dementia care, notes - we haven't voted to change things.

She said: "During the 1970s and 1980s, up until the early 1990s, most UK care was provided in the public sector, so any review of the current situation would have to take into account why that changed.

"I don't think it was rapacious private sector people coming in and taking over - I think it was the public sector deciding that they couldn't afford to do it anymore."

Prof Andrews, who has worked for decades in the NHS and the care sector, both private and charitable, describes herself as a socialist and trade unionist.

But she considers the idea of trying to nationalise social care "naive".

"Dementia costs more than cancer, heart disease and stroke put together.

"It's easy to say more money should come from Government, but it's much harder for any Government to say more money should come from you.

"Individual people are shocked about selling their house to pay for care. But you don’t hear many unaffected people crying out to pay more taxes and share the burden."

One of the most vexing issues for critics of the current system is that some of the major operators are owned or backed by hedge funds ultimately based in tax havens, enabling millions of pounds in profits - much of it coming from the public purse - to be siphoned out of the UK.

But Prof Andrews stresses that "increased income usually comes hand in hand with increased quality of care".

She said: "What seems to happen with reference care homes is that you hear 'the care home company can put profit in the Cayman Islands because they're bad at looking after old people'. That's a false association.

"The only reason any care home company has enough money to siphon profits into wherever it puts them is because they are good at providing care. Any care home that's bad at providing care stops making profits quickly.

"Say they've got 100 care homes, and one is failing. The local council will stop putting people in there. Families will go somewhere else. Just watch.

"A smart company will sack that manager and put in someone new to get it right. As a whole the company is probably still making a profit, but even one bad home can undermine the reputation and profitability of the whole business.

"They still have to pay the rent, staff and running costs even if it’s generating no income. It is in the company’s interests to provide good care.

"But people put it upside down and say the reason they’ve got money to send to tax havens is because they're neglecting the people in the care home."