Health and social care? More like health vs social care
By drawing on real world examples and personal experience, Louise Ahrens, an industry expert, explains health and social care must work together rather than against each other.
There is a gaping chasm that exists between health and social care which has widened like a grade four pressure sore. Necrosis is setting in. All parties are doing everything they can to avoid sepsis, but everyone’s hands are tied. The lack of staff, funding and in some cases apathy in social care, begs the question are problems in the sector too far gone, why try? We can’t change it.
The Japanese have a 15th century practice called kintsugi, whereby things that are damaged, broken, flawed, can beautiful again. kintsugi means ‘to join with gold’, a poignant reminder to stay optimistic when things fall apart. But these are more than hairline fractures that can be glossed over and made good, these are deep fissures, ugly voids. kintsugi may work for minor breakages and hairline cracks, but when the ceramic shatters and becomes shards, is it a futile jigsaw?
At the centre of this abyss are the patients who are waiting years for operations, waiting months for a care act assessment, being discharged from hospital with insufficient follow up care. A few decades ago, these people were occasionally falling off the cliffs, becoming an unfortunate statistic, they are now teetering on a frayed rope bridge over troubled water, and plummeting into the depths in their thousands.
Health stand on one side, social care on the other, and people are being lost to nihility.
We sit with our colleagues around virtual tables, we argue about whether it’s a ‘social care need’ or whether the ‘district nurses should be doing it’. We battle over who is responsible for completing a CHC checklist, which we all know is not going to have a positive outcome, we ponder whether someone who can’t reliably and safely take life saving medications should have a small package of care, ‘No’ say social services ‘We will do it do it if its ancillary alongside other care needs, but we can’t support solely for medications’. The NHS also say they can do no more, medications management have already been involved, Dr’s have reviewed it, various medications have been reduced from three times a day to just once a day at no detriment to the patients wellbeing. It is delivered to their home from the pharmacy in dated blister packs. A family member makes a two hour round trip each weekend to put the pills into a state of the art timed/alarmed dosette box that goes off at 1pm everyday, and, magically opens one small box to reveal the required pill. Sounds great, job done.
Mr Chowdry is 88, lives with dementia, high blood pressure and very poor motor skills. The alarm scares him ever time it goes off, he momentarily remembers the pill, he struggles to get it out of the dosette box, sometimes he drops it on the floor and subsequently forgets about it after straining to reach it, risking a fall. Other times he goes off to get a drink to take his pill, comes back, forgets the existence of the pill and sits down to watch the birds in the garden. The family member telephones at 1:30pm to check the pill has been taken, Mr Chowdry returns to the dosette box, next to his sleeping cat, no pill to be seen, ‘Yes yes, it’s empty for today, I’ve taken it.’
Mr Chowdry has not taken his medications, and the cat is slowly being poisoned.
Social services want to help, but it’s not really within their remit, the NHS want to help, but it’s also not really within their remit. Mr Chowdry suffers a huge stroke, spends weeks in hospital, more time in a NHS rehabilitation placement. After 12 weeks in a hospital bed, he then has to go into a council funded residential placement for the remainder of his life. This placement is 12 miles away from his home, making it an impossible journey for any of his elderly friends or neighbours to travel to see him unless they are adept at negotiating three different buses and a quarter of a mile walk with a walking frame and memory issues. The chosen home was ‘best value’ to the public purse. An understandable choice, but a very devastating situation for Mr Chowdry.
Everyone says ‘We could see it coming, it was only a matter of time before he ended up in hospital’. Was this a porcelain bowl we could have patched together, or was it inevitable that the bowl was going to fall and smash to smithereens? A fait accompli that we stand by and watch like rubberneckers at a car crash?
Working in health and social care involves a lot of clairvoyance. If you speak to anyone who has to complete care act assessments, frailty assessments or similar they will all have a number of soothsaying tales of when they predicted a broken hip, a ‘blues and twos’ episode, an emergency residential placement, an accidental overdose. We are not being neglectful, we do not want these misfortunes to blight our patients lives, but we are powerless to prevent them, for lots of reasons. 20/20 hindsight, week after week.
I have personally sat and cried int he care park before undertaking ‘duty’ within social services, as I could (accurately) predict that there would be four, maybe five more ‘deserving’ cases that need an urgent visit that day. They may need an emergency residential placement, have safeguarding concerns, or be out wandering about on the dual carriageway. There is no one to allocate them to. Which ‘urgent’ is more deserving? Take a choice, spin those plates in the air knowing kintsugi isn’t going to rescue any of them when they fall. Nothing is likely to end well, and there will always be a stressed out family member to shout ‘I hold you personally responsible if my mum falls and breaks a hip’.
When working within social services we were all sent on training so that our assessments could be ‘strengths based’. We were taught to look at what our clients could do, elaborate on this and consider the positives. This is great, to a point, but highlighting how fantastic Mr Paynes core strength and mobility is, and how at 78 he can touch his toes, doesn’t change the fact that he has lewy body dementia and sees snipers on the conservatory roof most days, and needs extensive support with all activities of daily living. His physical prowess and strength mean he can easily push his wife over and bolt out of the front door onto a main road to escape said snipers. Whilst we should all be encouraged to explore the positives and think creatively to utilise these, I do believe we also need to be acutely aware of the deficits to ensure that sufficient support is provided. The deficits exist, it is not prudent to ignore them.
There is no money tree, we all understand that. The expansion of the volunteer sector showcases this to perfection, and community-based approaches are being called upon now, more than ever.
I feel the need to point out that this article is in no way bashing either health or social services. I have worked in both, and in both environments there are plenty of staff who genuinely care, try to take a person centred approach, go above and beyond everyday, because they are aware that if they don’t go that extra mile, no-one else will.
The NHS and social services aren’t a stepping stone, they are the end of the line. If you require the services of either or both, then that need is unlikely to go away without help. That need could range from chemotherapy to compression stockings. There isn’t anywhere else to go, this is where the buck stops, and its a minefield. It’s complex for those of us who work within it, so it must be like negotiating a grim maze of thorns for others.
Is there an answer? Sadly, not really, but health and social care have to be more integrated. The present culture means that it is still very much ‘us and them’. If we consider the Venn diagrams from our school days, with the NHS on one side, and social care on the other, there is massive overlap, yet we continue to function as completely separate entities, silo working, blinkered to what our respective colleagues are doing.
Collaborative working is out there, in small pockets, but I know that colleagues from both health and social care want to give kintsugi a go, to try and harness an approach to holistic care.
Image: Louise Ahrens
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