It has been an irritating fact of life that successive health ministers have been so avidly keen to assure us of their passion for the NHS that social care – an equally vital element of our health and care system – has been systematically overlooked.
For social care campaigners like myself, it was notable that in the run up to lockdown, Jeremy Hunt, the former Health and Care Secretary, said on Newsnight: “In retrospect, I can see the cuts to social care were in a way the most silent and the most deadly”.
Social care has been starved of cash since the start of austerity, with over 400,000 fewer adults receiving council funded care now than in 2010, and many residential and home care providers living on the brink of financial disaster as a way of life. One of the saddest consequences of Theresa May’s misfire manifesto pledges in 2017 was to kick social care funding reform into the ‘too toxic’ long grass.
If the covid-19 crisis has done anything, it has shone a spotlight on the fractures that exist in the health and care system. The special treatment afforded NHS staff by the public and for supermarket priority queues is a surface expression of it.
The counting of deaths, GPs refusing to visit care home and the ‘mistaken’ letters, suggesting care home residents opt out of urgent covid care, also demonstrate a systemic bias. And the impact has been apparent in overall planning and preparedness and the availability of PPE to the care sector.
If NHS staff felt poorly prepared, trained and equipped for a pandemic then the same could be said for the care workforce many times over.
The crisis has exacerbated workforce issues in a sector where staffing numbers have already been hit hard by Brexit. Many care operators are struggling with supply of staff – not just due to sickness but also the lure of nurses back into hospitals.
Whilst a ‘land army’ of Eastern European workers have been flown in to work in farming, there has been no suggestion of vital reinforcements for the care workforce. The underlying systemic problem? A fundamental lack of a joined up health and care workforce planning, supply and training – and not just in the time of covid-19.
A care system starved of cash for many years will now be tipping over the brink. Without sounding unfeeling, care homes that have seen a doubling of resident deaths for this time of year will find it hard to attract and introduce new residents into their homes during lockdown and with the perception that the virus had taken hold in their establishment.
Anyone who has run care homes knows that some of the key factors for balancing the books are occupancy, agile staffing and the ratio between self funders and local authority funded residents. Occupancy will become a real issue. And if the warnings about local authority finance are true, this will have a serious impact on care operators – who have already endured years of shortfall between the cost of care and the fees councils will pay.
The crisis has also laid bare the challenges of having sufficient step down care – the specialist rehabilitation, community and care services available to free up critical care beds.
Every winter we be-moan older patients’ experience of delayed and unsafe discharge because of the lack of suitable care to speed a safe return home. If that’s true in most winters, then it is doubly so with the increase in corona virus patients.
It’s a good bet that recovery from the virus is neither instant or absolute. There is a suspicion that many patients who have survived covid may still have sustained damage to their lungs and other organs and missed out on effective step down care – both in hospital and on their return to the community.
Added to this, hospitals are reporting fewer and later admissions for people with stroke or heart failure and many people being treated for cancer or living with long-term conditions have had ongoing treatments curtailed to relieve pressures on the NHS. All these factors could be storing up a potential cohort of people vulnerable to a second wave of infections who desperately need rehabilitation and recovery support.
The crisis will however have unlocked some long standing blocks to digital and service efficiencies and its very unlikely that the genie will be put back in the bottle on all of those improvements. It’s vital that we continue those service improvements that patients tell us enhance their independence and self management and help the co-ordination of care.
Multi-disciplinary teams have proven benefits for supporting the care of cancer patients, people living with long term conditions and older people and digital systems can help co-ordinate them. In times of emergency, we gladly put our health in the expert hands of the medics who intervene swiftly to try to save lives. But once this crisis is over, we should make sure that patient centred care remains front and centre for further service improvements.
One of the clear gains of covid is that it has opened up a debate about the relationship between mental and physical health. Mental health, like social care, has long been a poor relation compared to other NHS provision, but we need to see greater understanding of the vital relationship between mental and physical health in how we care for people in all settings. Not just in the community but as soon as medical interventions happen and throughout care pathways.
Underlying all of the challenges faced by social care in this country is the lack of integration of health (mental and physical), and social care. Whilst integration has been happening incrementally region by region, through STPs and other structural and commissioning processes, it remains a disjointed for patients as they move within and between health and care.
This means we lack a clear line of sight on the patient journey and the long term health outcomes for individuals. For many people living with disability or long term conditions, the answer is often not to be found in hospitals but in the quality of person centred care available at home and in the community.
Exhausted as policy makers and leaders in health and care are bound to be after covid has done its worst, there will be a great opportunity to set about improving the whole system in the interests of patients and better health outcomes.
We need to bank the positives and not return to the negatives. Health and care need to be able to work better together. And social care should no longer be seen as the poor relation of the NHS.