by Jon Hyslop
As I understand it, this blog site is about looking at the opportunities for better social care. In my view we all have a strong genetic and social disposition towards valuing and supporting one another, which may be a suitably optimistic place to start. Most, if not all of us, also benefit from cultural, religious and philosophical traditions that embed these ideas, helping us to intuitively make good choices about supporting others. However the huge social changes over the past 200 years have made it difficult to sustain social systems of mutual support. The bureaucracies and institutions in which social care is embedded are recent inventions, and in some ways it’s no surprise that they struggle to keep up.
Many people reading this post will imagine that person-centred practice is at the cutting edge of modern social care, and may be surprised to hear one of the pioneers of modern social work, writing in 1981, describing the establishment of the welfare state the 1950s, in very similar terms.
“…social care … was based on realisation that individuals of any age must grow and be sustained as whole people if they are not to atrophy or become distorted as persons.”
Younghusband 1981: 18
During the early post-war period social care was stuck in buildings, sometimes the very work houses that the National Assistance Act 1948 had closed. In the 1960s care began to become available to people in their own homes, but it wasn’t until the ‘community care’ policy of the 1990s that a lot of the old long-stay institutions were finally shut. Nowadays it is nearly universally accepted that care should be provided in communities rather than in hospitals or care homes wherever this is possible. However, the concept of community is not straight-forward; it is mediated through culturally-informed expectations of relationships with other community members, of the opportunities communities offer people to lead the lives they want, and ultimately to become the people they want to be. These cultural expectations also vary according to age, social class, gender and ethnicity. The personalisation policies of the last decade often sought to work around this complexity by focussing exclusively on the individual. While the intentions were good, the effect has sometimes been to obscure the relationships with other people that give real meaning to the term ‘community’. The issues that I want to focus on in this post bring some of these ideas back towards the centre of the social care process.
In our explorations of support for personal budget (PB) and personal health budget (PHB) users in Oxfordshire, people have often told us that they needed more and better information. When we dug a bit deeper, many said they felt out of their depth, on their own, burdened by responsibility. Though expressed as a need for information, these feelings clearly had emotional and relational components that also call for a human response. This type of relationship can potentially be found in many places, for example with social care professionals, care workers and personal assistants, friends and family members, and other people in similar situations with health and social care services. Better social care requires consideration of how these relationships can be supported.
For many people, eligibility for state-funded support goes hand-in-hand with significant life-events such as psychological trauma, serious illness or permanent impairment. It should not surprise us that people will also be experiencing powerful emotions, and that engaging with these feelings is critical to helping people gain the confidence to move forwards with their lives. Yet contact with the state in this moment of crisis is often focussed on ‘care’ as an externalised object, to be quantified in hours and put into place as cheaply as possible and in the shortest period of time. This is not because professionals lack the theoretical knowledge, emotional warmth or willingness to engage. It is because they have been unwillingly positioned at the assessment gateway, where bureaucratic responsibility to manage risks and scarce resources (including their own time) precludes the types of relationship people actually find helpful. Fortunately, senior managers have realised that this approach is unsustainable and are seeking alternatives. The three conversations model being implemented by some local authorities advocates liberating professionals to work intensely with people at the point of crisis, which is definitely a step in the right direction. However it still falls short of the kind of long-term continuity that people say helps them to maximise control over their own lives. Meanwhile in the world of social work we have ongoing conversations about resilience, burn-out, short career lengths and high vacancy rates. The elaborate strategies developed to address these often miss the obvious – that social workers are not being allowed to do the thing that drew them into the profession in the first place. Better social care will involve taking professionals off the conveyor belt so they can get back to helping people.
Relationships between PB/PHB users and personal assistants were also an area of concern in our local work, and this is reflected nationally. Last year the 30.7% of the adult social care workforce left their jobs, with the highest turnover in private companies providing support to people in their own homes. Even before it became apparent that the toxic combination of fixed price and under-supply was leading to a race to the bottom in terms of quality, academic commentators had identified the inherent contradictions between care as a commodity and good quality care as people experienced it (Lewis & West 2014). Early on in the implementation of personalisation I met a young woman with no sight who rarely recognised the steady stream of new recruits that let themselves into her flat using the passcode provided by the agency, a far cry from the choice and control that PBs aimed to deliver. The principal omission of time-and-task models of care is the relationship between the people involved, which by definition ought to be caring. More recent research on the relationships between personal assistants and the people they work with has again confirmed that the emotional dimensions of the relationship are important to PB/PHB users, although managing this in a boundaried and ethical way is often challenging (Shakespeare et al. 2018). A better social care future is dependent on improving relationships between PB/PHB users, professionals and personal assistants, as well as the other people involved in the care process.
Relationships with other community members are also important. Local Area Co-ordination (LAC) is a relatively recent transplant from rural Australia, where the physical remoteness and strong tradition of mutual assistance provides the platform on which support is built. The co-ordinator makes use of local and personal knowledge to put people together with one another and with existing resources, only accessing statutory funds as a last resort. A key insight within this model is that when statutory resources are brought into play, they are used to ‘create new opportunities in the community’. Social prescribing is a similar idea, which looks likely to be rolled out as a part of the NHS Long Term Plan. Like LAC, the idea is to support people to access community resources, but in this case that support is commissioned through the NHS and focussed on general practices. Also like LAC, the literature highlights the importance of ‘building community assets’ instead of just harvesting them. While it’s great to see organisations like ADASS starting to talk about asset-based approaches, one gets the impression that some are simply seeing community resources as a cheap substitute for those purchased by the state. This overlooks the necessary role of the state in building and sustaining communities.
So far I have focussed on the groups of people who have already been historically positioned within the ambit of ‘social care’, but a brighter future depends on transcending these roles and identities. Thanks to pioneers in the disabled people’s movement, the importance of getting “…a life, not a service…” is widely understood. However, many basic local resources that used to provide social opportunities have disappeared over the last decade. A team evaluating integrated approaches to health and social care recently found that:
“Many of the sites had service models based on developing communities and self-care; however, the services that these models relied on (such as befriending services, lunch clubs, peer support, social activities, etc) had often been subject to financial cuts.”
Erens et al 2016:72
Nationally we are re-building from a low base, and this will take investment and time. A cut-and-run approach by the NHS and local councils is the opposite of what is needed. In Oxfordshire, local governments are taking some positive steps. The City Council has created a localities team to support development on a ward-by-ward basis, and the county has just completed its second round of small grant funding for innovative ideas for daytime opportunities and support. Nationally there’s a lot of great work on developing community enterprises and community business, led by the likes of Community Catalysts, Power to Change and the Plunkett Foundation. A better social care will be dependent on improving the opportunities available to people within communities, and this will require leadership within social care services to ensure that the assets of the state are transferred to communities rather than being withdrawn.
When social workers start talking about ideas like self-management and community resources, family carers often groan in anticipation. As the state rolls back, inevitably more falls to the family. This doesn’t have to be a bad thing, though. In my experience, the major problems are mismatched expectations, poor communication and trying to go from zero to infinity without taking baby steps. Early in my career I often saw family members give up work to look after parents with Alzheimer’s with no real idea of what they were taking on. How could they? The welfare state had absolved them of all responsibility until it couldn’t cope, at which point they were chucked in at the deep end. At that point in history we used measures of ‘carer burden’ to research the impact of closing institutions, a term widely hated by families who saw their relationships as a source of joy and fulfilment as well as being problematic. Positive new approaches such as Community Circles often start with careful mapping of people’s important relationships within families and beyond. This precedes negotiation about what people are prepared to do and any support or training they need. More widely good neighbour schemes, time banks, volunteer projects and so on can all develop people’s inherent capacity to support others, help them to work out their own limits, to find out what they can contribute, and to experience the rewards of doing so. All of us who work in social care have had friends say ‘Oh, I couldn’t do that’. Changing this is an important part of changing the wider narrative.
This post has focussed on the relationships most commonly thought as indigenous to the world of social care; those of service users with professionals, care assistants, family members and community volunteers. Ultimately, though, a better future for social care will need some of these concepts to be jettisoned. It’s now more than a quarter of a century since disability activists noted the tendency of ‘care’ to diminish the recipients by positioning them as dependent. Unhelpful cultural norms around work, illness, ageing and autonomy are all a part of the problem. Our ideas of social care are deeply embedded in an economic and political culture that is leading to widening inequalities, which are in turn increasing the very risks that welfare services were created to mitigate. A better future for social care must also be congruent with wider social changes focussing on reducing inequality and valuing lives more widely than their income-generating potential.
Jon Hyslop works with Community Glue CIC and teaches social work at Oxford Brookes University.
Lewis, Jane, and Anne West. (2014) “Re-Shaping Social Care Services for Older People in England: Policy Development and the Problem of Achieving ‘Good Care.’” Journal of Social Policy 43, No. 01 pp. 1–18. https://doi.org/10.1017/S0047279413000561.
Shakespeare, Tom, Andrea Stöckl, and Tom Porter (2018) “Metaphors to Work by: The Meaning of Personal Assistance in England.” International Journal of Care and Caring Vol. 2, No. 2 pp. 165–79. https://doi.org/10.1332/239788218X15187915600658.
Younghusband, Eileen (1981) The Newest Profession: A Short History of Social Work. Sutton: IPC Business Press.