Age concern: Donald Macaskill on ageism and coronavirus

The coronavirus crisis unfolding in care homes wasn’t much noticed at first.

It was not until weeks into the emergency that the public, media and political focus widened from the NHS to the care sector.

“I think that’s how people working in the care sector feel; it has aye been like that,” reflects Dr Donald Macaskill, chief executive of Scottish Care. “We have the darling NHS and the Cinderella social care. The reality is that as a whole society – and this isn’t about politicians, it’s about women and men in the street – nobody thinks about social care unless they’ve got somebody involved or unless it impacts on their lives directly.

“It’s just not in the public’s imagination.”

Macaskill, who holds a PhD in psychology and sociology, is a specialist in palliative care and bereavement, and used to run his own equality and human rights consultancy. He has been at the helm of Scottish Care since 2016. The organisation represents 400 private, not-for-profit and charitable care providers delivering residential care, nursing care, day care, care at home and housing support services, and has been elevated higher in the public consciousness lately thanks to Macaskill’s knack for publicity.

Three weeks ago, he set off a row over the provision of PPE to Scotland during a BBC interview, claiming that the UK’s four largest suppliers had said they were not sending to Scotland. Westminster health secretary Matt Hancock subsequently stated that the UK government had made no request to the companies to prioritise England.

It’s not just PPE care professionals have been worried about. There were initially concerns about a presumption against transferring patients from care homes to hospital during the crisis (the First Minister later made clear that there should be no such presumption) and about GPs refusing to visit care homes (reports of this have sharply decreased).

Macaskill still worries about whether there is enough testing capacity to fulfil promises to test everyone in a care home who is symptomatic.

He was also disappointed by COVID-19 Guidance: Ethical Advice and Support Framework – guidance published on April 3 to help clinicians make difficult decisions in the event that there were too many people in need of treatment and not enough beds, staff or other resources to treat them – having said it raises more questions than answers and lacks a robust articulation of human rights.

The guidance is being continuously reviewed and in any case, capacity has not yet been reached in the NHS. Nevertheless, Macaskill says that together with the NICE guidance (for England and Wales) it has raised “profound concerns about what is an acceptable ethical framework for the care and treatment of individuals in the whole of society”.

“Our argument has consistently been that each person should be treated as an autonomous individual and that in a resource-restricted environment, you make a decision, not on the proxy of age or frailty or co-morbidity but that you understand collectively – and age is one factor, it’s not to deny that – but that you make a judgment based on the best clinical outcomes of using depleted resources.”

One area that prompted concern early on related to DNACPRs (do not attempt cardiopulmonary resuscitation decisions). It is appropriate to ask individuals and families about DNACPRs as part of someone’s anticipatory care plan; what worried Macaskill and others was people being asked about DNACPRs simply because of their age. For instance, some GPs were apparently assuming that anyone in a care home who developed Covid-19 would have a DNACPR.  Macaskill says his concerns on this have diminished but not disappeared.

Scottish Care is seeing between 84 and 86 per cent of individuals who develop Covid-19 survive, which is both a high mortality rate and striking evidence that the great majority of residents will fight off the disease.

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Was the care sector prepared for Covid-19?

“No, it wasn’t. It was as prepared as it could possibly be. Could we have started things earlier? I’ve no doubt that we probably could, but Scotland’s care homes went into lockdown on 12 March which was much earlier than elsewhere in the UK.”

He hopes that this crisis will prompt a wider debate about care, insisting that the funding model is “fundamentally broken” and that “we have got care on the cheap for decades”.

“This crisis should hopefully highlight that you cannot keep people safe – and you cannot ensure that you do so in a manner which upholds their dignity – by paying staff as poorly as they are, albeit that we celebrate the Scottish Living Wage.”

But how do private companies fit in to this? Many people are deeply uncomfortable with private firms making profits out of caring for people at the end of their lives. Indeed, over the years there have been very poor inspection reports for some privately run homes.

Macaskill responds that business models are more diverse in Scotland than elsewhere, with more not-for-profit providers, as well as private ones. He claims the majority of those are Scottish-based companies, often with only one family-run home. (Big UK companies do operate numerous homes in Scotland.) “I think there might have been very genuine concern a number of years ago about the care home sector as being a source of making revenue and profit, but I think if you speak to smaller, private operators, those days have long since passed.” He says this is due to the cost of delivering care.

Right now, the focus is coronavirus and he is going into bat for the over-70s over the easing of lockdown restrictions: “Any blanket assumption that if you’re over 70 then you’ve got to remain at home for a longer period, I would challenge as being discriminatory and actually with no basis of validity epidemiologically or clinically,” he says.

The debate over age discrimination won’t end when the Covid-19 crisis does.