There was policy among the politics in Wednesday’s Queen’s speech, although not all of it was necessarily pulling in the same direction. For political consumption the Government is offering a new clamp down on the rights of non-UK nationals to access our NHS services. Let’s see if it proves more consequential, or electorally satisfying, than the many clamp downs that have preceded it. On the policy side, the government is taking important steps to reform social care, capping individual liability for some costs, introducing new rights and prioritising early intervention support. The social care sector will need to grow and change radically in order to meet the aspirations behind the proposals. Whether this will be helped or hindered by restricting the ability of migrant social care workers – on whom the sector has been highly dependent – to access health services while in the UK has yet to be seen.
The kindest interpretation of events is that the Coalition is deliberately underlining that the way we’ve expanded our caring capacity as a society in recent years is unsustainable, fiscally and socially. We cannot continue to rely on professional services, often offering low-pay, low-prestige jobs, intervening at points of crisis or severe infirmity and offering relationships between carer and cared-for that are so tightly rationed that care itself struggles to keep a foothold. A high-quality care sector can only be part of the solution to living well in a silver society. A much larger role needs to be played in future by softer interventions that maintain wellbeing, respect independence and nurture social-interdependence across the life-course. With its stress on reducing people’s dependency on formal care services through earlier intervention, the Care Bill is a useful step in the right direction. But as a pamphlet we published this week argues, its attachment to needs rather than strengths may ultimately perpetuate a system in which rationing around individual thresholds distorts our overall social investment and can create perverse individual incentives and unfair outcomes.
We believe that the Bill should go further. At the same time, we believe that the onus for change doesn’t rest exclusively with the Government, or even local government. How we function as a society will need to change as who we are as a society changes. Work in support of the National Dementia Strategy is instructive and important in this respect, reframing a medical condition as a social challenge with implications for communities and employers, as well as health professionals and care services. In a paper that we published last year, Craig Berry struck some important cautionary notes; yet many of the opportunities for improving the lives of our older citizens lie outside of traditional services. For example, we are currently working with Asda to explore how they could operate in ways that generate greater social value. The amount of store space that will be needed for retail is falling, so what other functions could the store spaces provide? How could stores like Asda, in partnership with community groups or mainstream public services, create opportunities for isolated older people to come together, share skills with each other or with younger people, perhaps learning how to pool personal budgets in order to access care that they would value? We have also been working with the Scottish Environment Protection Agency and Scottish Natural Heritage to look at the role of access to high quality natural environments in supporting health and wellbeing throughout the life course. The importance of green space for healthy childhoods is now widely recognised, but designing healthy green space for active older communities is just as important, yet receives relatively little practical attention.
It’s unfortunate to see our older population routinely referred to as a burden, a timebomb or – more recently – the sharpest teeth in the LGA’s jaws of doom, threatening imminent financial breakdown. A whole-place, strengths-based approach doesn’t substitute fantasy for reality, but it is useful because it puts all of us in the frame.
Paul Buddery is Partner at RSA 2020 Public Services. He tweets at @buddypb
Matthew Taylor has recently written several blog posts about the need to reconsider care. His suggestion that secondary school pupils should be required to do 100 hours of caring as part of a compulsory work experience programme seems like a good one for lots of reasons.
Acquiring the skills of caring early in life can only be an advantage, and raising the profile and status of care are important likely benefits of such a scheme. In general I think working with young people in schools is a valid way to try to achieve cultural shifts across a generation.
Shouldn’t offering care be something that we all do, in some form, and continue to do throughout our lives?
But I also think that it can be an effective strategy for sidestepping our own responsibility to contribute in areas that we recognise as important, but might not want to engage with directly. For those of us who left school years ago and are busy working full time, developing our careers, or in Matthew Taylor’s case, running the RSA, the idea of doing a bit of hands-on care as well might seem unfeasible, not to mention unappealing.
If we are in broad agreement with Matthew’s arguments, shouldn’t offering care be something that we all do, in some form, and continue to do throughout our lives? It occurs to me that there might be scope for companies and organisations to set up schemes in which employees are encouraged to offer their time as voluntary carers during work hours.
There is at least one precedent in which a company has decided to donate employees’ time to charities. The housing association, First Ark Group, has recently made the decision to donate 500 days of staff time to volunteer in local good causes. In the Guardian’s report, published on Monday, First Ark explain that they see their responsibility to the community as extending beyond doing their ‘bread and butter’ work in the best way possible. Being a force for good and building genuine connections with the community are also key priorities and donating staff days is one way of making these things happen.
There is plenty of evidence to indicate that volunteering is good for us. It’s not just good for our communities and for the organisations, individuals and groups who receive voluntary help, it’s also good for the volunteer. In addition to the fact that volunteering brings the opportunity to learn new skills and build different kinds of relationships, it’s also good for our overall wellbeing. It has the feel good factor.
So, if an organisation were to introduce a caring scheme, what would it mean for the workplace? I suspect it would be likely to increase morale amongst staff, raise pride in the employer, develop a reputation for being a socially responsible organisation. If staff throughout organisations, from chief executives to managers to cleaners were all expected to participate, it would give the entire workforce a shared experience and sense of solidarity.
What about the likely costs? How could any company afford to donate staff time to offering care? What would the impact be on individuals’ time management and workload? According to First Ark, these problems are easily ironed out quickly, and all it takes is a bit of adjustment. Tot up the amount of time staff waste at the water cooler, and we already know that being present at work 100% of the time doesn’t amount to 100% productivity.
It will be interesting to see how First Ark’s scheme works out, and whether they continue with it beyond this year. It seems to me that if we really care about care, we should be prepared to demonstrate that by actually getting involved ourselves. The way working life is structured makes it a tall order to expect people to volunteer to care in their spare time, but I wonder how prepared we would be to do it if it became part of our working lives.
35 social care professionals, local authority representatives and policymakers discussed reforms to the draft Care and Support Bill at an event hosted by the RSA’s 2020 Public Services Hub. Alex Fox FRSA, CEO of Shared Lives Plus, guest blogs about the event and Bill.
There can be few people unaware that there are NHS reforms afoot in the UK. Yet few are aware that the most sweeping social care reforms in post-war history are now taking place, with existing ‘poor-law’ based social care law to be replaced by new legislation outlined in the draft Care and Support Bill.
The Care and Support White Paper which preceded the Bill set out a new vision for the ‘personalisation’ of social care. This takes the idea of individuals having an individual choice of service and control over their lives as read, but recognises that even a well-funded, well-tailored service does not always add up to a good life, particularly if your support needs are social rather than entirely physical. For instance, taking a cash Direct Payment in lieu of a service to hire and manage a team of Personal Assistants can be the ideal solution for meeting physical support needs while staying in charge of one’s own life. One individual who now manages his own care said, “When I got my disability I was stuck in hospital whilst services argued over paying for adaptations to my house.” Yet if someone’s challenges involve isolation or social exclusion, the solutions are likely to lie partly in that individual’s unpaid relationships with families, friends and others in their community.
The reorganisation of social care around promoting wellbeing is a radical and welcome vision. But there is concern that the draft Care and Support Bill will not fully enable this vision in practice. Five pioneering community support organisations -Community Catalysts, In Control, Inclusion North, Inclusive Neighbourhoods, Partners in Policymaking, Shared Lives Plus, as well as a leading Director of Adult Services – have argued in a briefing on the draft Care & Support Bill that the Bill needs set out a different route into – and out of – social care to achieve an affordable, more empowering and more successful care system.
In particular, the care organisations argue that eligibility tests should not be the first conversation which people have when they encounter social care. Instead, they should be offered support with life-planning as the first intervention. These personal planning discussions would look first at the individual’s strengths and skills, rather than considering only their needs; then at their existing supportive relationships with family, friends and the wider community; and lastly at services. The wellbeing principle should be developed to set out in plain English a minimum acceptable level of wellbeing to replace the current Fair Access to Care Services (FACS) eligibility criteria.
The recommendations are based on the care organisations’ experience of how people are changing lives and communities for the better, often with less money than has been spent on traditional services. At a recent roundtable hosted by the RSA’s 2020 Public Services Hub and chaired by Paul Burstow MP, who currently chairs the Joint Committee scrutinising the draft Care and Support Bill, one participant said that the current system intends to be empowering but “drags us back” into a deficit-focused model and “dependency culture”. In contrast, when disabled people and family carers themselves are involved in explaining support options to others, there can be a more honest conversation. A parent said, “When I had my daughter in the 1970s it felt like I’d fallen down a rabbit hole into a world I didn’t know existed. I had no support strategies and was battling every day to get simple things. Other local parents were holding on to what they knew and were wary of change.”
Likewise, Partners in Policymaking runs citizen leadership courses for disabled individuals and the parents of disabled sons and daughters, and brings families together for peer support and to influence decision makers. Before the courses participants say that they would often “just talk about their problems, not about what would make things better”. After completing the courses, many people get jobs and some set up groups or social enterprises to tackle the challenges they have experienced: “I would have been one of those parents who wrapped my daughter in cotton wool, but I started to see her as a citizen of this world with the same rights as others and now she’s done two degrees. We learnt to ask for what was needed, not what was on offer and we built a community. One young man would have gone into residential care when his Mum went into hospital, but with support from the network he is still living at home after seven months.”
Moving away from the mindset of “These services are what we have on offer” towards “What would you see as a good life and how can you move towards living it?” represents a huge culture change, particularly at a time when many services are in crisis mode. Mechanism changes such as personal budgets, implemented in the aim of personalising care, have not always created change of this kind. Though some councils, providers and professionals have implemented personal budgets, these are still used to buy the same old services staffed by the same people. In contrast, two social entrepreneurs described how they had built upon the skills and insights they had gained working within public services to identify a gap in current provision, going on to set up their own small enterprise which provides transition support for young disabled adults which is tailored to their goals in life. They are just one of around 800 micro-enterprises known to the partner organisations.
A new social care law cannot legislate for culture change of this kind. But, while Direct Payments remained little used for a decade after they were introduced into law, the cultural shift towards individual control which eventually followed them would not have happened without the original legislative change.
Some councils are already trying to make a change of this kind, even within the present system, with FACS tests replaced by questions which could be used to define acceptable wellbeing such as: Are you safe? Can you live with dignity? Do you rely upon services for personal care? Are you connected to those around you? Are you able to be an active citizen in your community? A personal planning approach which helps people to find, recognise and use all kinds of resources and relationships, including family care, community groups and new links to people in similar situations, will often find ways of improving wellbeing without relying upon services.
However, developing a different approach to care with local spending cuts of up to 40 per cent is clearly a challenge: “we are reneging on the welfare state commitment made in the ’40s, with no evidence that the taxpayer will step up. So we either abandon those goals, put our hands in our pockets, or take collective responsibility and have a new public discourse on care.” Or as one council representative said, “it’s not ‘doing more with less’, it’s doing ‘different’. We need to remember that we are often the minority partner in the provision of care and to be careful about where we are putting our big feet. The economy of regard doesn’t function in ways in which we always understand.”
Last month my colleague Sam McLean posted a blog asking whether social capital was necessarily always a good thing. He was right in saying that too often we take it as read that strong social connections and a high level of trust create better outcomes in every scenario and on every occasion. While it is true that there has been a long standing debate about the merits of social bonding capital (connections within groups) vs. social bridging capital (connections between groups), this has really only skimmed the surface of what is a much more nuanced issue.
To give you a better sense of what these nuances actually look like, I’ve collated a few interesting examples about how complex social capital plays out in semi-formal and informal care settings. Before I lay these out, the first thing to mention is that, broadly speaking, social capital is a good thing when it comes to caring for older people and helping to maintain their independence. Eric Klinenberg’s famous study of the Chicago 1995 heat wave found that mortality rates among older people were much lower (30 per cent) in the neighbourhoods where they trusted others and felt safe to leave their buildings. Likewise, we now know from the work of John T. Cacioppo and others that health outcomes are directly linked to levels of loneliness and isolation. The risk of Alzheimer’s is said to be twice as high in older people who are lonely compared to those who are not.
All of that said, there are a number of reasons why we should be giving social capital a closer inspection, particularly when it comes to informal care and adjusting to an ageing society. The following points illustrate that the relationships and trust we have with others are neither homogenous, nor stable over time, nor indeed always positive:
1.There is a clear distinction between the support provided by neighbours, friends and family – the kind of care that older people receive is often ‘relationship-specific’. It has been suggested by some academics in the field of social care that spouses are the ones who provide both deeply emotional and physical support, adult children the emotional and instrumental support, and friends and neighbours the lighter companionship. No doubt all of these are important to older people but it does highlight the fact that neighbours and casual acquaintances are no substitute for close family when it comes to doing tasks that are of a very personal or physical nature (an important point when we think about housing policy, as my colleague pointed out recently)
2. Relationships are fragile and likely to change in times of illness – in a report on the social exclusion associated with ageing, AgeUK points out that the social stigma attached with certain illnesses can diminish or entirely sever even the strongest of friendships. The report includes the story of one man who felt like a ‘social pariah’ after his diagnosis of dementia: “Acquaintances would ‘pretend’ not to see me if I was in their presence and people stopped inviting me to dinner or events. They assumed I had changed in ways that I hadn’t, that I wasn’t the same person anymore and wasn’t worthy of conversations”. Friendships do not always weather the storm of illness.
3. Friends and family can be hyper-controlling and sometimes the best individuals to help older people with managing risks are those they have no relationship with at all – Fear can pervade the close relationships that older people have with their relatives and friends, often to the extent that the latter can become overly protective and risk averse. Care from close relatives and friends can turn into ‘containment’, severely limiting people’s independence. The same AgeUK research highlighted before found that some older people feel more comfortable discussing things with strangers who are impartial and who have ‘no vested interests’.
4. Older people do not want to be a burden to friends and family – Surprising research by Ipsos MORI shows that older people are far less enthusiastic about living with their children in old age than are their children. This is in part because they do not want to receive ‘reluctant attention’, but it is also perhaps because they fear the health consequences that may affect their spouses, children and close friends. Indeed, CarersUK found that nearly half of all carers providing significant support were in debt and affected by stress as a result of caring. Few would want to bring those kinds of difficulties on their loved ones.
If any of the above proves of interest, look out for an upcoming report from RSA Projects on risk, trust and an ageing society.
If a measure of a society is how it treats its weakest members, how would the UK currently fare? Judging by last night’s Panorama investigation we would certainly be below par. The episode showed hidden camera footage of an elderly lady with Alzheimer’s being mistreated, ignored and occasionally physically abused by not one but numerous care staff that visited her on their rounds. All bad enough on its own, but what makes this story truly depressing is that it wasn’t presented as a high-profile scandal per se, but rather something which is run-of-the-mill, everyday behaviour. A cursory glance would suggest we’ve become casually acceptant of abuse and dulled to stories of neglect.
All of that said, it would be both lazy and unwise to attribute such behaviour to ‘bad’ people or to see this as just another sign of a moral collapse in society. First, this account simply doesn’t ring true for other care homes across the country where the quality of care and carers alike is often superb. Just last night I came across a great initiative called My Home Life which shows the great things that can be done to improve the quality of life for older people in care homes. Second, there is a danger that in dismissing certain individuals and institutions as inherently abusive we neglect the underlying, often systemic, drivers of such behaviour. As one Twitter observer put it, “enough of the voyeurism, let’s have an intelligent discussion about the underlying problems of #ukcare”.
Such an intelligent discussion would no doubt have to include a fair analysis of the current care investigation processes led by the Care Quality Commission and at least some exploration of what effect the move to private sector care provision is having on service standards. But above all any conversation about the root causes of maltreatment in care homes or outside of them would need to look at how carers are recruited, how much they are paid and what kind of pressures they are under in their working environments. In short, do we care enough for the carers?
When it comes to rewarding carers for the demanding work expected of them, probably not. According to a recent study cited by Gavin Kelly of the Resolution Foundation, there are potentially between 150,000 to 220,000 care workers in the UK who are on less than the minimum wage. This is an astonishing figure. Even for those whose employers do everything above board, their pay rarely sits much higher than the £6.08 minimum and many have to cover the costs of long distances of travel to and from work themselves. On those kinds of wages, how does anybody expect to recruit truly caring individuals who are willing to invest themselves in their work?
Likewise, similar problems are witnessed in the recruitment and general management of care workers. In a piece of research into risk and caring published by the Joseph Rowntree Foundation last month, it was noted that the private agencies supplying carers as personal assistants did not know enough about the background of the workers on their books. As one lady who was interviewed in the research put it, “I needed a personal assistant and advertised through my local care provider. They sent me a list of ‘suitable’ people to interview. One of the candidates was a young lady… who I had known when in hospital and knew how potentially disturbed and violent she could be. The care providers who recommended her had no idea of her background and her care manager was pushing her to get work.” Incentivised by payment-by-results schemes, this push by private contractors to get people back into work may worryingly lead to more ill-suited and undertrained individuals heading into the care sector.
All of this seems to be symptomatic of a social care system in the UK which is, to use a clichéd term, not fit for purpose. The obvious solution is that care needs to be more highly valued, the wages of care workers increased, and the recruitment and management of workers reappraised. But this will no doubt take time and effort. Nor will fixing the systemic processes necessarily address what is often a cultural problem on the part of a few care workers, although the two of course overlap.
What is needed instead is something that draws upon the ability of those already doing great work in care to mitigate the actions of those who aren’t. One option is to encourage more whistle-blowing in the sector. But this comes with several caveats, not least that it can take months if not years to follow up on the calls made by concerned care workers. A different, more direct approach would be to train the most diligent care workers in an organisation to look out for potential signs of abusive care in their organisations and to mollify them before they escalate.
The emphasis here is on prevention of abuse rather than identifying and punishing people after it has occurred. Like ‘the interrupters’ who prevent violence from escalating on Chicago’s roughest estates, the care workers charged with such a role would take subtle steps to encourage a better culture of care among workers. In practice, this could mean taking conscious steps to change the tone of the conversations between their colleagues, stopping them from reaching a situation of group-think where they blame older people for things affecting them.
This seems like a particularly soft way of addressing what is a serious problem, and it would also ask a great deal of the individuals who were to take on such a role. But such a highly localised approach would be able to get to where regulation and other system changes cannot. Above all, it recognises that there are exemplary care workers out there and would try to make the best use of their abilities to turn the tide in poorly functioning care homes.