One of my lifelong sources of irritation is that I am ridiculously short-sighted which makes the daily middle aged misplacement of spectacles really annoying.

It took me a long time to discover there was a ‘Sunday’ name for all this. According to the dictionary ‘myopia’ is the name for near sightedness and apparently it is becoming more common. But it also carries another meaning for to be myopic is also to have a lack of foresight and intellectual insight.

As I sit writing this blog there seems to be a growing tendency towards myopia amongst some of the health and social care planners and strategists that are influencing decisions across Scotland today.

Scottish Care publishes its latest report on nursing today. It paints a fairly depressing picture. There are increased vacancies, exorbitant nurse agency costs and more nurses leaving care homes to join agencies than ever before.

In response Scottish Care is working with colleagues from the Chief Nursing Office along with others to address many of these challenges. But as well as those interventions I have a concern about a wider, maybe even systemic, failure to appreciate and acknowledge the changed clinical environment we now live and work in. This is especially noticeable in some of the debates around the future of nursing in the care home sector though by no means uniquely there. There is an unwillingness to accept the significantly enhanced levels of dependency of those in care homes who require 24/7 clinical support.

Alongside this in the last few days I have read plans and proposals which effectively imagine a greater dependency on informal care in our communities and a greater reliance on an already fragile homecare sector across Scotland.

To be independent whether in our own home or in a homely setting must surely be the ambition we all want to achieve for both ourselves and our loved ones. But independence in the sense of living on your own supported by family or others is not possible and cannot be possible for everyone. The mantra of independence at all costs may seem to cash stretched Integrated Joint Boards as an easy solution but in essence it is a dangerous road to start walking down. Independent living without appropriate safeguards is neither responsible nor is it safe.

Over the last decade we have seen an enormous change in the number of people being supported to live in both care homes and in the community with enhanced and significant clinical care needs. The description I hear the most from staff is that ten years ago most people walked through the doors of a care home whereas now most have such high levels of support needs that they are rarely able to self-mobilise.

In our communities too there has been a growth in the number of people being supported to live independent lives and for whom a decade ago a hospital or care home might have been the only options open to them.

So in general, therefore, there has been a rightful re-orientation from clinical to community settings. But this has its limits. To continue to maintain or place people with high levels of clinical care in the community without an adequacy of clinical support and appropriate resourced clinical governance either in care home or their own home is irresponsible and unsafe.

Too many family carer groups tell me they are on the edge of exhaustion. They can’t have yet more placed upon them. Too many professionals recite instances where the risk of those they care for is unacceptably high and we are only a hairs-breath away from a serious incident.

There is a real danger of a care myopia which allows us to make care decisions based on the right principles but with the wrong outcomes. Quality care cannot be cheaply purchased nor delivered. The social care system in Scotland is in need of radical re-orientation and prevention is surely the key. But prevention is only possible if there are adequate supports to enable it and we are in danger of losing these. Preventative care cannot be developed within the parameters of greater risk.

At the moment I am witnessing a real lack of vision in an awful lot of the plans and proposals I see. The tendency to reach for the fiscal scissors and cut out services is a reactive one with little basis in clinical or care reality. It is evidence of limited imagination and even less far-sightedness for what care and support needs to be in the Scotland of the near-future.

Those who are in need of care, those who are vulnerable in our communities, who cannot and should not be left on their own in the name of ‘independence’ and ‘self-management’ deserve better than the restrictive visions of a limited, over-stretched, risky care currently being offered as the future in some places; for they are a short-sightedness based on fiscal criteria which serve us poorly – they are nothing short of a care myopia.

Dr Donald Macaskill

@DrDMacaskill