Isolation is a double-edged sword: for infection prevention and control it means an island safe from the invasion of the coronavirus, but for many in this increasingly globalised age it means an island cut off from, or lacking, social interaction. For older people it can mean loneliness and death. Adult social care has to deftly navigate the threshold between these two extremes. For young people isolation means being cut off from education, friends, social life, hobbies, and employment. For older people it means being alone without conversation, family, friends, exercise, fresh air, fun, and participation.

In the midst of a Scottish winter and the covid-19 pandemic, recent reports and communications reveal the isolation paradox in terms of the needs and opportunities for enhanced localised care training. The anticipatory care initiative asks older people whether they prefer to have emergency care at home or in hospital. [1] During the earlier wave of the covid-19 pandemic, the risk of dying from the virus was more than six times higher in a hospital or residential care home than in someone’s own home. [2] Yet visits from social care staff may be the only social interaction for older people. [3] Such social isolation is associated with an approximately 50% increase in the risk of developing dementia. [4] 

High numbers of covid-19 deaths in care homes were associated with people of advanced age and underlying health conditions being confined in shared environments. [5] The care at home survey reported on the reduction and sometimes complete withdrawal of care at home during the pandemic. Continuity of care highlighted the need for designated carers to reduce the number of staff entering homes. [6] Communities, friends, neighbours, volunteer groups, unpaid carers, all provided practical and emotional support. [7] Recruitment and training of new care staff was limited. Adjusting for age, people in the most deprived areas were over two times more likely to die with covid-19 than those living in the least deprived areas. [8]. Self-directed support (SDS) gave care users an opportunity to achieve meaningful choice and control, but meeting their desired outcomes through SDS was sometimes problematic. [7] The pandemic has increased unemployment for young people aged 16 to 25 moving from education into the labour market in Scotland—they have few job prospects. [9]

We need to address all these needs and opportunities head on with the “passion,” that the philosopher Søren Kierkegaard’s 1844 manuscript suggests that paradoxes engender. [10] The Scottish Government should seize the opportunity of covid-19 to access emergency soft loans for five years to pay for enhanced localised care training. In line with their commitment, this training will support people to “stay at home or in a homely setting, with maximum independence, for as long as possible.” [11] 

Enhanced localised care training has multiple benefits. It returns choice and control of designated care to users. It reduces travel time, pollution, costs and the risk of infection being spread by non-designated care staff. And it ensures that care investments are retained in disadvantaged communities rather than being siphoned off. 

The training programme should be facilitated and managed by local community councils, volunteers, and faith groups working with the local medical practice and Healthcare Improvement Scotland’s anticipatory care team. With anticipatory care, each older care user may opt for emergency care “at home” or “in hospital.” This reduces the incidence of ambulance, hospital and consequent care home use. The training programme should be trialled in an area of multiple deprivation reporting to the Scottish Independent Review of Adult Care before being rolled out in other health boards. [12]

Selected and supervised by older care users—along with their neighbours, friends and designated carer—local “conversation carer” trainees aged 16-25 should be awarded funded apprenticeships. This will allow experienced designated carers to reduce their usual duties in proportion to the trainees’ “conversations” with care users. The time that experienced carers have available for training may increase, along with their enhanced NHS equivalent pay status. 

Trainees should be vaccinated and equipped with face masks, PPE and a pre-programmed smartphone. Their primary role is to engage in an hour’s daily “convivial conversation” with an older care user, while responding to their requests for help with dressing, washing, cooking, cleaning, walking, exercising, ensuring ventilation and social distancing, using phones and the internet to contact friends and health and social services, finding lost spectacles, helping toilet use, fixing smoke alarms, and other tasks.   

After one year of the covid-19 emergency programme, each trainee should be assessed by the care users, their neighbours, friends and designated carer to be awarded fully funded social care training in Scottish colleges and universities. In this way, the paradox of isolation during the covid-19 pandemic will evoke Scotland’s passion to provide high-quality humanitarian care for the rapidly increasing numbers of older people. 

Bruce Currey, Academic health researcher, Clackmannan, Scotland.

Competing interests: none declared

Acknowledgements: BC thanks Gregor Abel, Thomas Blackadder, Philippe Chastonay, Richard Coyne, Anne Dawson, Remo Grasso, Rosamund Gruer, Jamie McKenzie Hamilton, Euan McMillan, John Lee, Cora Paterson, Yue Zhuang.

References:

1. Baughan P, (2020) Coronavirus and Care Planning Conversations. Health Care Improvement Scotland. NHS Scotland. http://www.healthcareimprovementscotland.org/our_work/coronavirus_covid-19/care_planning_conversations.aspx
2. National Records of Scotland (NRS) (2020) ‘Deaths involving coronavirus (COVID-19) in Scotland’ 14th October https://www.nrscotland.gov.uk/news/2020/deaths-involving-covid-19-week-41-5th-to-11th-october
3. The Scottish Government Adult Social Care Winter Preparedness Plan 2020-21 and Evidence Paper. https://www.gov.scot/publications/adult-social-care-winter-preparedness-plan-2020-21/
4. National Academies of Sciences, Engineering, and Medicine (2020). Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care. System. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663.
5. Reilly J, Crawford D, O’Boyle D (2020) Care Home Review. A rapid review of factors relevant to the management of COVID-19 in the care home environment in Scotland. The Scottish Government. Edinburgh November https://www.gov.scot/publications/root-cause-analysis-care-home-outbreaks/
6. Scottish Parliament (2020) How has Covid-19 impacted on care and support at home in Scotland? The Scottish Parliament. Edinburgh. https://www.parliament.scot/S5_HealthandSportCommittee/Inquiries/Care_at_Home_Survey_Results_Nov_2020.pdf
7. Care Inspectorate (2020) Delivering care at home and housing support services during the COVID-19 pandemic. Care Inspectorate inquiry into decision making and partnership working. September. Dundee. https://hub.careinspectorate.com/media/4171/delivering-cah-and-hss-during-the-covid-19-pandemic.pdf
8. National Records of Scotland (2020) Deaths involving COVID-19. Wednesday, 16 Sep 2020. https://www.nrscotland.gov.uk/news/2020/deaths-involving-covid-19
9. The Scottish Government (2020) Towards a Robust, Resilient Wellbeing Economy for Scotland: Report of the Advisory Group on Economic Recovery. Report from the Independent Advisory Group established by the Scottish Government to advise on Scotland’s economic recovery in the wake of the COVID-19 pandemic June. Edinburgh. https://www.gov.scot/binaries/content/documents/govscot/publications/strategy-plan/2020/06/towards-robust-resilient-wellbeing-economy-scotland-report-advisory-group-economic-recovery/documents/towards-robust-resilient-wellbeing-economy-scotland/towards-robust-resilient-wellbeing-economy-scotland/govscot%3Adocument/towards-robust-resilient-wellbeing-economy-scotland.pdf?forceDownload=true 
10. Kierkegaard S (1844) The Absolute Paradox (A Metaphysical Caprice) Chapter III. Kierkegaard’s Writings: Philosophical Fragments, or a Fragment of Philosophy/Johannes Climacus, or De omnibus dubitandum est. VII, Volume 7 p37. Editors: Howard V. Hong and Edna H. Hong (1985). Princeton University Press. Princeton. New Jersey.
11. The Scottish Government. Reforming adult social care support. Edinburgh. https://www.gov.scot/policies/social-care/reforming-adult-social-care/
12. The Scottish Parliament (2020) Initial Inquiry. Social Care Inquiry. Edinburgh. https://www.parliament.scot/parliamentarybusiness/CurrentCommittees/113970.aspx