Cars (A Care in the Community Story)

Pat Wylie

‘Care in the community’ took off in the 1970s and 80s. At that time, NHS bosses were facing up to the high cost of running a vast network of hospitals, alongside most people’s wish to receive care at home whenever possible. It seemed to make sense that small, roving teams of nurses could deliver equally good care to people in their own homes, saving the NHS money, and allowing patients more privacy and comfort than hospital can offer. Around the same time, the monolithic Social Work (Scotland) Act 1967 placed a statutory framework around a wide range of child and adult welfare services that were previously the preserve of churches, charities and dispassionate local bureaucrats. Central to the development of community care was the car.

In community services, most workers use a car. We rove from house to house, dispensing everything from pain relief to parenting advice, in a sector that first blossomed in the era of cheap petrol and motorway construction. The areas we cover are often geographically disparate: large towns or districts that might share the same postcode or town hall but which sprawl out to distant historical or administrative boundaries.

Throughout the sector, job descriptions routinely specify that the applicant ‘must have own car’ – quite a tricky requirement when you’re recruiting front line home care staff to be paid less than eight pounds an hour. Our expenses claims are routinely referred to as ‘mileage’ despite that they encompass public transport expenses and other costs too.

But we care for people who have little chance of owning a car any time soon. We work with vulnerable young families experiencing severe poverty and with adults whose disabilities mean they could never get a driving license, or have had to give theirs up. There are times when having a car assists us in carrying out our duties – in the course of my work I have helped people load every single one of their belongings into the boot of my car as they move between homeless accommodations – but there remains a discrepancy between a workforce that relies on cars, and a clientele that can scarcely imagine owning one.

Meanwhile the cost of petrol, and the visible impacts of climate change, render driving an increasingly expensive and guilt-ridden task for us all. As the current regime of austerity brings greater centralisation of services; we are seeing the closure of community buildings, health clinics and even local sheriff courts, causing longer journeys for all concerned.

The cost of owning a car continues to rise, while wages remain stagnant and glaciers melt; but our local public services continue to live by the outdated ethos that care is by car.


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What was I supposed to do?

Pat Wylie

A few years ago, I was employed as a sessional nursing assistant for the local health board, mostly working in general hospitals and helping patients with washing, dressing and eating meals. One night, I was offered a night shift in a psychiatric hospital. I needed the money, so I agreed to work the shift.

“You’re in IPCU”, I was told when I reported for duty that night.

Having never set foot in a mental health hospital before, I had to ask what IPCU stood for. I was gruffly informed that “IPCU” stood for Intensive Psychiatric Care Unit: the ward that accommodates the most mentally unwell patients.

I had had no training in the care or safety of mental health patients; I must have worked in psychiatric hospitals on numerous occasions without receiving any formal training in mental health. I now understand that, at a minimum, the health board should have trained me in the safe management of aggressive behaviour by patients before allowing me to work there. I would also have benefited from some training on common mental health conditions and how to support people experiencing mental distress. No such training was offered to me. I was always sent to work as an extra staff member, each time as a one-off, to bring the patient/staff ratio up to a minimum legal standard, so why train me? What could possibly go wrong?

Luckily there were no critical incidents, as far as I recall, during my time working as an occasional staff member in adult mental health hospitals. I would occasionally take part in ‘escorting’ patients in a taxi from one hospital to another in the dead of night. I would often be called upon to supervise patients while they smoked cigarettes, or to serve light meals to patients while observing basic working practices that are designed to reduce incidences of self-harm in hospitals, such as preventing patients from having access to scalding hot water or metal cutlery. But even these working practices were something I picked up on the job, rather than something that was formally discussed or explained to me. As a curious person, I often wanted to ask why some of these working practices were in place; but the answer was often ‘that’s the way it has always been’.

That first night, and other times when I worked occasional shifts in mental health hospitals, I had absolutely no idea how to provide therapeutic care to adults with mental health needs. In all the years I’ve been working in health and social care, I have always felt that there is no substitute for experience, and no training like training on the job. I am broadly in favour of not pathologising or medicalising people experiencing acute distress, and I certainly wouldn’t want to demean or mistreat people experiencing mental distress. But it took me many months to feel as though I was ready to work in mental health hospitals, partly because I had had no training in how to do so safely, and partly because everyone else – patients and staff alike – always seemed far more familiar with the rules and norms of mental health hospitals than I ever was.

Over the following years, I came to enjoy my occasional jaunts to work in psychiatric hospitals. I gradually realised that, while there is no point in generalising people who experience mental illness or distress, they tend to appreciate simple things like being listened to and treated with respect. But I have never entirely shaken off my alarm that I was sent to work in acute mental health care with zilch, diddly squat and zero relevant training or experience behind me.

I was a lowly nursing assistant. What’s worse is my suspicion that a good many newly qualified nurses and doctors, those who have not specialised in mental health, find themselves in similar positions at early stages in their careers, dealing with patients in general hospitals and in the community whose mental health needs may be very complex. Mental health care requires confident staff. A basic level of training in mental health care is the least that patients and staff deserve.