A Crisis of Care: Scotland's care homes face a difficult winter ahead

In the days following the Queen’s death, many were caught off guard by their own feelings of grief for a distant and unknowable public figure. However remote from our daily lives, the monarch’s passing ended an era which, for the vast majority, had begun before our births and was bound up in memories of parents and grandparents.

Many of us have lost loved ones recently. Since the appearance of Covid in early 2020, nearly 180,000 deaths have been recorded in the UK within 28 days of a positive test. Due to the restrictions that were in place, many died alone, their funerals sparsely attended and socially distanced. Indeed, the image of the Queen at Prince Philip’s funeral, sitting alone and wearing a black face covering, has become of the defining images of the pandemic.

But while few lives have gone untouched by the pandemic, those living in care homes have suffered more than most. At the start of the pandemic and with demand for hospital beds surging, the decision was taken both in Scotland and elsewhere in the UK to send elderly patients back into residential care often without testing them for Covid first. 

Between March 1 and May 31 2020, more than 3,000 untested hospital patients were discharged into care homes in Scotland.  It was a decision now seen as one of the biggest mistakes of the pandemic.

Donald Macaskill, chief executive of Scottish Care, a charity which represents private care homes, says many of the measures subsequently put in place to protect vulnerable older people ended up having negative consequences.

“The damage done by certain measures, ostensibly to protect, became a continual abuse of human rights,” he says. “We did not hear the voice and the experience of individual care home residents. There is always a tension between the need for collective safety and the desires of an individual and I think as a whole system, we got that wrong.”

Macaskill says that staff working in the sector have been left physically and emotionally drained by the pandemic. And yet, Covid has not gone away. Macaskill says around 80 care homes are still under some form of restriction, despite many believing the worst of the pandemic is behind us. 

“Even when people were pulling up the deck chairs in the summer and acting as if Covid was over, the care sector was dealing with the challenge of people still contracting the disease despite vaccines, boosters etc., and some people becoming extremely ill,” he says.

“Anyone who thinks this is like cold or flu is deluded, and things are not helped by a political and media system that is so desirous of returning to normality that it ignores the reality that Covid is still remaining a challenge for the care sector…”

And yet despite the rigours of Covid and the impact it is continuing to have on residents, Macaskill says the biggest challenge is yet to come. He says soaring energy prices have left care homes wondering how they will survive the winter, with many reporting a 1,000 per cent increase in the cost of gas and electricity.

“Personally, I’m more worried about the impact of this winter than I was in the winter of 2020,” Macaskill says. “Hopefully, mercifully, unless Covid really changes, we’ll not see people dying to the same extent. But I’m really concerned about the sustainability of the social care sector in Scotland, around which the NHS is fundamentally dependent. 

“There’s a myth out there that, particularly in the independent care sector, it’s full of multinational organisations – that is not true of Scotland. The majority of private providers in Scotland are small, family-run, often single operators who simply don’t have the resources or revenue – even in good times – to meet those sorts of exponential rises.

“You add to that the cost-of-living crisis on food, non-energy utilities, the impact on the workforce, and I’m really profoundly concerned about the financial stability and the ability of a really exhausted cohort of workers to get us through the winter.”

Donald Macaskill says this winter is likely to be difficult for care homes | Credit: Holyrood

Macaskill says a typical 50-bed care home would normally expect an energy bill of between £26,000 to £36,000 a year but is now being quoted eight to ten times that figure.

“With Covid, certainly by winter 2020 when vaccination was beginning, we had a sense of hope and optimism that there was light at the end of the tunnel,” he says. “At the moment, our belief is that the lights are going to go out and that we will quite literally struggle to make it through the winter.”

It is against this difficult backdrop that the current politicking on social care is being played out. When he became prime minister in 2019, Boris Johnson promised to “fix social care once and for all”, eventually introducing the Health and Social Care Levy, which aimed to address chronic backlogs in the NHS alongside longstanding problems in the delivery of social care by making workers pay an extra 1.25p in the pound in National Insurance contributions.

But amid the cost-of-living crisis and with a difficult winter looming, Liz Truss has pledged to scrap the levy less than a year since it was introduced. Macaskill says that would leave a “fiscal hole” as well as unanswered questions over the implications for Scotland.

North of the border, the Scottish Government plans to introduce a new National Care Service. Described as the biggest policy intervention since devolution, local council have called it a “power grab”.

Macaskill says the National Care Service is currently a “massive distraction” from the day-to-day realities faced by the sector.

 “At the moment, there is such a lack of detail in the bill and associated documents that it is not clear what the future is going to be like. The National Care Service is seen as a massive distraction from the day-to-day reality of trying to keep going and survive through this winter.

“People do not have the energy...to contribute to the conversation around the National Care Service. We’re standing on a burning platform and it’s burning from both ends. The promise of a National Care Service is, at the moment, a mirage which is not going to save us from drowning.”

So, should further discussion of the initiative be postponed until such times the sector is on a more even footing? 

“I know that the trade unions and others have called for a postponement,” Macaskill says. “We have fundamental issues that we’ve got to deal with. I don’t see why we can’t deal with those at the same time as having a debate which is less about legislative change and the establishment of a new structure and more about the essence of what that National Care Service needs to be.

“Having been a sceptic initially, I am someone who believes we need substantial system change. We have a failed system in its current format, so the status quo is not an option.” 

As if things haven’t been hard enough over the past couple of years, the sector has been further undermined by Brexit, that singular act of self-harm which has not only failed to provide any of the promised “opportunities” but has instead left a series of difficulties in its wake. For Scotland’s care homes, particularly those in rural areas, the most significant is the difficulty in recruiting staff. 

“The debate about the National Care Service is all very well,” says Macaskill, “we can come up with the best ideas, the most innovative proposals, but they need people on the ground. That’s what we lost with the phenomenally gifted women and men who had made Scotland their home and felt they need to leave the country. We’re not able to recruit to the level that is necessary.

“Yes, the Home Office has improved things and the visa processes are easier, but for a social care economy like Scotland’s, with so many SMEs, the sheer practicality of recruiting internationally has become virtually impossible.”

I ask Macaskill if Covid, Brexit and now the energy crisis have coalesced to create a perfect storm for the sector.

“I sometimes wake up wondering what major apocalyptic disaster is going to be visited on the care sector this week. Many of the problems facing us were there in January 2020, but nobody listened to them. They were compounded and deepened by the pandemic and yet the sector didn’t fall over because of the astonishing professionalism of the women and men working on the frontline.

“Then we were faced by a huge workforce crisis partly because of the Covid trauma and the negativity around the social care sector which meant we lost lots of people to retail, hospitality and other sectors who had nowhere to recruit from in terms of international recruitment. So, Brexit hasn’t just hit direct recruitment, it’s hit our ability to retain staff who have gone to sectors unable to recruit from Europe.” 

When the Queen died earlier this month, Macaskill had been preparing for the launch of a report by the UK Commission on Bereavement, on which he sits. Launched in June 2021, the Commission has been gathering information on the key challenges facing the bereaved and the emerging issues caused by the pandemic. It’s chaired by the Bishop of London, Sarah Mullally, who gave a reading at the state funeral. After Elizabeth’s death was announced by Buckingham Palace, it was decided to postpone the release of the report, which will now be issued at a later date.

“There’s a generation which has a particular resonance with the Queen,” Macaskill says. “For many people who are in care, but also those who are supported in their own homes, it’s been a subject they’ve wanted to talk about and reflect on. For many people it’s caught them by surprise that it’s put them in touch with their own feelings about parents, about partners or someone significant who is no longer in their life. The collective grieving has impacted and brought to the fore individual grief.

“For staff [in care homes] it’s been a challenging time because they’re exhausted on the back of an extremely stretched summer. On top of all that, this major emotional and psychological moment has been very tiring.”

In a blog published after the Queen’s death, Macaskill wrote that he was “saddened” by the notion that we should mourn less someone who has reached the age of 96 compared with a younger person.

“There’s an immense hypocrisy around bereavement and grief,” he says. “We make the assumption that our personal response to the death of a relative should be mirrored in the response of other people. It’s inappropriate to place on an individual a hierarchy of emotion...grieving is profoundly individual and unique.

“People often make the comment about someone ‘having a good innings’...it’s suggestive that an older person has less to contribute than someone who is younger,” he says. “If there has been somebody occupying the role of matriarch or patriarch in a family, their loss is disproportionately more intense the older they are because we don’t know life without them.”