When the welfare state was established, it was on the basis that people could be categorised into two groups: people who were ill, requiring health care; and people who were frail or who had a disability, requiring social work support.
Two distinct services were developed: the NHS to cater for the sick; and social work services, provided by local authorities to support the disabled and frail. his has been the case since the NHS was established in 1948 and the welfare state was formed in the late 1940’s and early 1950s.
Fast forward to today and 60 years on we are on the brink of fully implementing the Public Bodies (Joint Working) (Scotland) Act 2014 to bring health and social work services together. Why is this important? Because people’s lives don’t operate in separate health and care silos and services for older people are even less likely to categorise their needs in this way.
It makes no sense to an older person who has fallen at home that their injury is to be treated by the NHS, but a different body will make sure that they have carers to visit them a couple of times a day to support them to cope at home independently again. It makes even less sense to them (or anyone else) that they might need to stay in hospital until that is arranged. And primarily that is what the agenda to integrate health and social work services is about: getting older people out of hospital and back home as quickly as possible, sorting a problem that is somewhat inhumanely described as “delayed discharge”. It is clearly the right thing to do: older people don’t do well if they are in hospital longer than they need to be.
They are at risk of infection and they can become less able to cope when they are at home. Hospitals should be about treating illness and getting people well; integrated health and social work services should remove delays when people move between services, with all the benefits that brings.
In doing this we need to remember that we cannot fix a problem with the system if we focus on only one part. We cannot make an older person’s experience better by just focussing on getting them treated and discharged. We need to address both ends of the system. Do they need to be in hospital in the first place? If so, from day one we need to be working to make sure they stay well when they go home. Older people often end up in hospital because in a crisis, A&E is the place they can go for treatment: families might feel a frail relative needs to be checked out, GPs might have nowhere else to turn on a Friday evening when a sick and frail older person presents for treatment and is not well enough to go home alone.
For an older person, A&E is often not the best place to be. We need to divert more people from hospital to safer alternatives as much as we can. If we get to a place where only people that really need to go to hospital go to hospital, we will support our older population much better. This means investing in rapid response social care services and making sure GPs, family and carers know these are available. This is difficult to think about in winter when pressure in hospitals is at its greatest, but this would be life changing to older people and cost saving to the NHS.
We can also make sure older people can come home from hospital as soon as they are ready. But that is almost entirely dependent on our social work care at home workforce. Without home care workers to support people back to full health or help them cope with diminished abilities in their homes we will never get people out of hospital quick enough. And there are real and growing problems with the availability of this workforce.
There are issues around pay and conditions. The opening of a new supermarket paying above the living wage can attract staff away from caring, leaving big gaps in the teams needed to support older people. But it is not just money. It is about people seeing home care as an attractive, rewarding job and the start of a career. It is about being able to recruit in the right places in rural areas. It is about valuing this workforce and developing it into a sustainable part of the health and social care system. And it is about recruiting more men and people from all parts of society. But crucially, we need to offer carers the chance of a career as well as a job.
• Alistair Gaw, president of Social Work Scotland