Blog - potential reconstruction challenges for social care leaders post-lockdown

This blog offers observations about the future strategic challenges facing social care leaders, and ideas around how best to plan to meet those challenges. It has been prepared by IPC Associate Consultant, Mick Mellors.

The Covid-19 pandemic is having a profound effect upon the population at large and the health and social care services dealing with it. There are likely to be huge changes in services as we move towards a 'future normal' state in the coming months, and there will be much work to do to make this shift as painless and successful as possible for the long-term. In a related IPC blog, Lynda Bull has made the point that strategic leaders need to think beyond the current ‘battlefield’, capture the experience, reflect on the learning and redesign services for the future.

While this strategic leadership will be crucial for the long term, it will need to be complemented by equal attention to issues that are likely to arise in the immediate aftermath of the lockdown period, not least in terms of people’s emotional and psychological adjustment to the experience. The diagram below from the US Disaster Technical Assistance Centre (Zunin and Meyers, cited in DeWolfe, D. J., 2000, p.5) illustrates some of the potential experiences for people in response to an experience such as the Covid-19 pandemic.

In the last few months social care services have borne much of the brunt of the pandemic in terms of providing services, taking precautions and managing risk. The response has made unprecedented demands upon staff and required services to focus their attention, shift priorities, re-deploy or concentrate their resources and delay, defer or limit their activities in other areas. Many staff have been working flat out or in brand new roles. New arrangements and ways of working have suddenly been introduced and will need to be properly evaluated before being retained for the long-term. Many health or care needs have been postponed but are likely to re-emerge with the end of the lockdown period. People have been under great pressure, the release of which will inevitably lead to some form of reaction.

So, in addition to thinking about the long term funding, resourcing, design and delivery of care, social care leaders also need to consider how to help people – staff, partners, patients, people who use services and their carers - in the more immediate aftermath of the lockdown period i.e. the ‘reconstruction’ stage on the diagram above. Each service, organisation or system is likely to face its own localised challenges but there are at least three main areas where an early response is likely to be needed:

Demand

Clearly, the emergency will not be over as we see the number of new cases in the first wave continuing to decline and lockdown conditions ease. Even when numbers have reduced to a much lower level there will still be new patients requiring treatment and care and it is likely that many of those who have been seriously ill with Covid-19 will require ongoing treatment and social care support for some time. This is not the place to discuss medical issues in-depth, but for some there will be ongoing problems, and these will add further pressure on services that provide long-term care and support.

Some people say that “funerals are for the living, not the dead”, and there is no doubt that the restrictions on attending funerals in this period will, for some people, have got in the way of the grieving process, and this on top of the experience of having someone swept away following a short and distressing illness. The impact can be profound and long-lasting and the capacity of care services to support people, as well as the availability of formal psychological support will be important.

In addition to the issues of grief, bereavement can bring other problems for people, including financial difficulties and being able to cope. Many older people, for example, care for a spouse or partner or share in co-dependency. The loss of one partner to Covid-19 may create problems for the other that require support from services. Some local authorities may want to consider the resourcing of bereavement support services. They may also find that there is an increase in demand occasioned by the need to support people previously cared for by someone now not able to do so.

Leaders will also need to think carefully about how to respond to potential significant rises in demand for a whole range of services as the lockdown period eases, and short-term interim family support arrangements end. In addition to those whose assessment or treatment has been deferred, there will be many who will have themselves delayed referral or have been supported within their own community by family and friends, not least because of the lockdown. As yet it is not clear what this might look like or how it might be dealt with. There needs to be close monitoring of trends and, where possible the modelling of immediate future demand, using both that trend analysis and any other intelligence available from across the system. Commissioners should already have been monitoring the availability of services and the pressures upon them but will need to continue to monitor with providers their continuing capacity and flexibility, particularly if there is to be an upsurge in demand.

Staff and staffing

There have been many stories of local authority and independent provider staff working tirelessly under pressure and at great risk to themselves over the last few weeks. Some studies suggest that the Covid-19 death rate ‘significantly higher’ in social care workers than health care staff in the last few months. Certainly, many care workers have contracted the virus and will suffer longer-term effects. Some may experience PTSD, which can have short-term and long-term consequences, whilst others will suffer from simple fatigue – potentially no less significant. Many will simply want to take a holiday. In any event it seems likely that in the immediate aftermath of the pandemic there will be staff issues to be addressed relating to capacity, fatigue, trauma and entitlements.

Dealing with these issues is going to be a major task for leaders and will require both planning and the marshalling of resources both to maintain services (at what might still be a time of exceptional demand) and to support staff. Leaders in local authorities will need to ensure that commissioners support providers in anticipating and responding for their staff groups also. There are three possible elements to this:

1. Screening staff for signs of fatigue and trauma, recognising that they may be unwilling or unable to recognise this and flag it up themselves.
2. There also may need to be arrangements to support those staff by managing their workload and/or providing suitable counselling support. This may be especially difficult if there is a spike in demand for services generally, as indicated above.
3. There may be a need allow staff to access their entitlements to annual leave or other forms of absence and this may require temporary staff to provide the necessary cover to maintain services.

Pandemic arrangements

‘Pandemic arrangements’ is a catch-all term for all the things that have been done differently as a result of the Covid -19 pandemic – some out of necessity and others for expediency. These include, for example, national guidance such as the easement of Care Act duties and on payments to suppliers to ensure continuity of service, and local arrangements such as shutting or restricting some services, wider use of technology, taking new approaches to collaborative commissioning and having more integrated working around hospital discharge.

Many services affected by the re-deployment of staff and other resources and the furloughing or home-working of staff will need to re-start. For some that will be as simple as just opening-up again, but for other it is likely to be far more complicated than that. Planning the re-opening, redesign or scaling-up of services will need careful consideration, particularly as staffing resources may still be limited. Also, as the pandemic tails off, decisions will need to be made about the extent to which vulnerable people can be brought together safely in settings such as day centres or taken out into the wider community.

Also, a wide range of physical resources have been provided and/or shifted to meet the needs of the pandemic. Others will have been closed up. Some will need replacing, some returning to their original location and some will need to be disposed of. Temporary facilities may need to be continued, closed, returned to their original purpose or developed for new purposes.

Some of these new arrangements will have been seen as positive and refreshing and the harbinger of more effective working in the future. Others may be seen as necessary in the short-term, but unsustainable in the long-run. Leaders will need to make evidence-informed decisions about the impact of these changes, and which should stop, which should continue and which should be further developed. This will need to be undertaken quickly and succinctly – and a recent blog by IPC Associate Melanie Henwood suggests that Real Time Evaluation might be a useful tool to help with this. In any event, it will be helpful to compile and maintain a log of those changes that have been put in place across the organisation and to review the impact of each of them.

Following the initial period of the pandemic there will of course need to be renewed attention paid to financial resources. We are in unchartered waters but we all know that social care finances will need attention. There have been revised financial arrangements in a number of areas (for example, the arrangements for both local authority and NHS contracting and payments) and these will need to be reviewed and potentially revised. There will be much work to do to re-set (or re-create) organisational budgets, including taking account of responsibilities to the many small and medium size social care enterprises that rely on local authorities for their income.

There is no doubt that whilst the pandemic has had tragic consequences for many people and caused a massive upheaval in society, it has also opened the way to some new and improved ways of working. As with any crisis, it has allowed us to find and utilise new resources from within ourselves as individuals, as professionals and as commissioners and providers. In some instances it has shown the way forward for new and more effective ways of working, with many lessons learned that can be put to good use in the future.

As we hopefully come out of the initial lock-down period over the next few weeks it will be crucial that social care leaders support their staff and colleagues to begin to build arrangements for a more sustainable long-term future in social care. However, in doing this, the aftermath to the initial crisis will present its own challenges and difficulties and these will need to be addressed at the same time. If we deal with this period successfully, we can perhaps move more constructively towards a better, more sustainable longer-term future for people who need and work in social care.

References

DeWolfe, D. J. (2000). Training manual for mental health and human service workers in major disasters. 2nd ed. Edited by Diana Nordboe. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.