An open letter about the future of health and social care

As this challenging year comes to a close, it is a good time to reflect on the challenges we have all had to face. In my line of work, I often have to state uncomfortable truths. That has put me at risk of horrible media attacks, even from advocacy organisations that I regarded as allies in the fight for the rights of older people and people affected by dementia.

Recently I was asked to provide further comment on these uncomfortable truths. This was my response:

To whom it may concern,

 1. People have done an amazing job in keeping services going.  

But, in respect of leadership and workforce challenges in health and social care, the pandemic has not changed my view that the job of leaders in the NHS and social care is made almost impossible.  

 It is by a supreme effort, extra resources and a reduction in targets and scrutiny that they have kept the system from collapsing entirely.  They have been helped in this by staff returning from retirement, a flood of volunteers, students abandoning their education to go to the front line, removal of any control on spending on extra staff, removal of waiting times limits, increase in delays to investigations and treatments and, to an extent, reduction in demand from people who have held back from attending hospitals or other services.  And also, rapidly discharging as many older people as possible from acute hospitals.  Now, nine months later, the leaders and the workforce are exhausted.  That pace of working could not be sustained.  As the system steps down from a pandemic footing, it cannot be allowed to go back to what was there before.  It needs to be changed so leaders have a job that can be done.  Being constantly micromanaged by government departments makes their work impossible.  There was a joke circulating before the pandemic, that if a nurse drops a bedpan anywhere in Scotland, the health secretary is distracted from what she should be doing to check up on it. The situation in the other parts of the UK is hardly better. Health ministers are policy experts, not health and social care experts and they are selective in the advice they accept. Strategy and operations need to be separated further.  The chief executive should have health management expertise and not be two doors along the corridor from the politician.  This needs to change.

2.   No good will come from blaming private sector business practices for failings in care homes 

One important lesson to be learned is that no good will come from blaming private sector business practices for disasters such as the mass deaths of older people in care homes.  Any prior prejudice about businesses who profit from providing care cannot be reinforced by claiming that a public sector care service would have done better with the regulation, information and funding as it stood at the time.  It is mere speculation.  In any case the reason for moving care to the private sector in recent decades was to save public money, at the behest of the public sector and politicians. For whom we voted. If there is blame, it lies with those who placed older people in this situation in the short term during the pandemic or the long term through successive government policies.  It is outrageous to outsource employment practices, indemnity responsibilities and care standards to another employer, and adopt a self-righteous attitude while hand wringing over what happens next.   The two sectors, particularly in care of older people, are so inextricably linked that blaming one side or the other is fruitless.  Whipping up public sentiment ‘for’ the NHS and ‘against’ care homes creates as many problems for the government as it does for the businesses.  It is short sighted.  A large part of the national need for health and social care is about older people and the whole system is not age appropriate for this predominant demographic.  It is a commonplace of blame cultures that when there is a system failure, someone within the system gets the blame, rather than anyone taking an intelligent look at the system as a whole and learning from experience.  That needs to change.

3.  We can move forward by improving the public understanding of how to prepare for old age

This statement is true for ourselves, our families and our own community, and making sure that the system will focus on those who would fall though the net.  The perverse incentives that are created by the financing of care of older people through local authorities need to be changed, to prevent hospitals having too many medically fit older people who are waiting for discharge. A commissioner for older people would be a good start. 

In summary, my view has not changed on these three issues, but my concerns expressed about older people in the health and social care system in March this year have been borne out by what happened the months following.  Age Scotland in particular suggested that I was unnecessarily frightening older people and tried to shame me for that.  Well, it turns out old people had good reason to be frightened.  If advocacy organisations focussed more diligently on health and social care issues at the hard edge, government may be held more to account for those things over which they have control and would be less likely to blame others when disaster strikes.  Fear of being blamed for system failures is what led to increased insurance premiums for care providers, and defensive visiting policies that have separated families for almost a year.  

In conclusion, my view is that this is going to be a very difficult time and only through radical, focussed and well-informed leadership, without ideological prejudice, are we going to get anywhere in the next five or ten years.  

Yours sincerely

Professor June Andrews

 If you would like more information, you can buy my book Dementia, the One Stop Guide or Care Homes: When, Why and How to Choose a Care Home. I am available for consultancy for families or organisations. And if you have any further queries or questions, or suggestions for something you’d like to see me write on, please contact me via the Contact Page

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