I thought this would be a useful guide to those people who are trying to navigate the complexities of health and social care in the UK. (Today, July 2018).
This explanation I hope will be a little different to those you can download from NHS or Council websites as it will be my take on the matter, including, possibly, misunderstandings that I have – with the assumption, that if I, as a supposed specialist in the area of older people have the wrong idea, there will at least be one or two other people out there, in society who also have it wrong.
So, this is generative. It is an attempt to understand and I would be delighted if people who have more insight and understanding that me, wish to amend or contribute!
Let’s start with some definitions:
Healthcare (again, all of this is UK and I suspect it is all different in Wales, NI & Scotland) (I am in England, for international readers) – is considered those aspects of a person which impact on their mental or physical health. That’s it. It is split in two; a dichotomy of sorts.
Health > Physical and Mental.
We all know that many years ago Descartes saw the problem here, yet, in 1948 when the NHS was established it was determined that the two would exist separate yet together.
If you have a problem with your body – heart, lungs, skin – you see a physical health doctor – a GP or physician/surgeon-specialist; if you have a problem with your mind – depression, anxiety, psychosis, you see a mental health worker, and, perhaps, if you are fortunate (in the resource poor world we live-in) a psychiatrist.
When you have a problem between the two, for example, asthma which we know has strong physical and psychological components, you are stuck, ping-ponginig between the disciplines. If you are very (and I mean very) lucky, you will have access to a psychologist who can sit with a foot in both camps, although they are even more difficult to access in our system than psychiatrists.
The decision way, back when the NHS was created was for healthcare to be delivered free at the point of delivery – A&E, GP surgery and open to all – whether you are rich or poor, you can walk into a hospital and have your appendix fixed without receiving a bill. (Unless you are a health tourist – that is again, another blog).
And so, things shuffle along.
And yes, it struggles. A system that was planned for a country whose demographic, age profile and economy was very different, teeters, trying its best to follow first-principles, frequently failing, most often those who are vulnerable – the old, people with mental health conditions and continuously the staff, those who provide the care, through burnout, compassion-fatigue and low job-satisfaction.
Yes, things are changing. That is for another day as nothing is different now (at scale); and, if you are looking for someone to help you get to the toilet at three in the morning, this is an imperative now.
Social Care – I can’t even begin to suggest I will do more than scratch the surface; this is an entire academic discipline. Yet, my understanding is, that social care, in England, relates to any care that a person receives that is not health (i.e. disease related).
Clearly, as with mental and physical health, there is a huge overlap – and I think it is easiest to understand thinking of a continuum; full health and no social care requirement at one end (perhaps, Bear Grylls) and sickness and full support at the other (for some reason an image of Stephen Hawking pops into my head, although that might be inappropriate.) (Yesterday was his memorial service at Westminster Abbey) (Ironic, I know).
And, a central tenet of this is the cost thing.
You see, social care is not free, unless that is, you can’t pay.
I don’t know the financial aspects of this and indeed, I have never managed to fully understand how it works with people who own their own houses. I imagine it is easy if you have cash in the bank – if you need someone to check you are up in the morning (and don’t have anyone, family or friend to do that for you) (at least consistently), the options are to pay for a disembodied voice – so called ‘call’ services, “Mrs Kersh, are you well this morning?’ kind of thing my mum might have heard.
If you can’t contribute, the council will pay.
Sure, this is not as good as someone popping-in and checking on you, but it is better than the fear of being found collapsed, dead, on your carpet at the weekend when your family call round to visit.
This is the obfuscating world of social care which as I say, starts with a buzzer and ends with you living full-time in a nursing home; again, this is a continuum. I won’t use any famous people this time to illustrate.
Initially, or to begin, you might just need someone in the morning, visiting to make sure you are out of bed, then to see if you have managed breakfast, then, getting dressed, washed, taking your pills.
Visits are calculated on the basis of time-based aliquots of activity; ten, fifteen, thirty-minute calls. The more dependent the person (the less they can do for themselves), the more help they require, when things get tough, sometimes two people are needed for one visit – in extreme situations, even more; these people (they are usually the young women you see sitting in old cars on street corners wearing blue or green uniforms, early in the morning) will visit mostly, up to four times a day (described as ‘calls’) and do whatever is needed; re-heat meal, help with washing, dressing; oversee the administration of medicines.
All of this is means-tested, which is, so long as you have adequate funds, you will either have to pay for all the support or a portion; it isn’t always all that bad, as often people who need support receive payments from the council – Attendance Allowance and other such monies (again, all changing continuously), this means that the council give you money that is then paid to private companies to provide care – it is a great way of keeping shareholders of Uber-organisations in large cars and holidays abroad (sigh, such a cynic am I).
You could call it circulation.
Within all of this is a separate system of assessment which determines whether your social needs, in other words, say, ability to get dressed are affected by ‘just’ ageing and general decrepitude (sorry for that word), or the whole thing is affected by health – for example, someone who has a stroke and cannot dress themselves is in a different situation to someone who is just aged; I know this is not apparent, but, when understanding the system you have to disconnect sometimes from logic.
In the latter case, the health service (Clinical Commissioning Groups) in England, will pay towards some of the social care – they will contribute a portion of the money that then joins the onward movement into shareholder bank accounts.
It is tricky navigating and negotiating all of this.
If you are lucky you will have a savvy social worker to help you.
If you are even more fortunate you will have an articulate and forceful son or daughter who is able to fight the system for you.
If you aren’t you will probably struggle.
The system in many respects is fantastic.
It is great if you are in need of significant support; you don’t need to have taken-out private health insurance at age 18 and it will continue until you die (indeed, those in the last three months of life don’t have to worry about any of this, the NHS pays for the lot).
This doesn’t help if you, your mum, dad or partner has just experienced the life-tsunami of a stroke or onset of Vascular Dementia (the latter being another physical/mental/social care minefield).
Find a social worker. One who cares. Most do care. Unfortunately, the system we work inside is particularly uncaring. It is dumb. It is sometimes a bastard.
I am coming to the end of Hilary Cottam’s book ‘Radical Help’ and found the following insight fascinating –
Over the years, councils (the near-you face of Government) try to save money; they achieve this by cutting-back services. Moving towards more responsibility and dependence on the self. This is a see-saw, dependent on the ruling party’s philosophy – left or right.
Frequently, at least for the past decade in the UK, the pendulum has swung towards restricting benefits.
10 years ago, if you couldn’t walk 20 meters you might have received a parking badge, now you have to be unable to walk five; that kind of thing.
Interestingly, the people doing these assessments – doctors, nurses and social care staff, instead of saying to Grannie Evans, ‘Oh, the new rule says that 10 meters is OK, I’ll revoke your credit,’ they reassess Grannie as being only able to walk five.
Cutbacks thus cost more money and create a greater sense of dependence.
This is the system squeezing people into a manipulation of care and compassion. Consequently, humans behave like humans and skew the data towards humanity.
Perhaps if we had robots objectifying ourselves this wouldn’t be a problem.
Oh, good lord, no.
For Nigel, Julie and Inge.