By Professor Bob Hudson
As howls of betrayal, dishonesty and untrustworthiness reverberate around our political system, there is renewed interest in the idea of ethical behaviour – what it is and how it can be better embedded in public and business life. New ideas are coming from unlikely sources: many of the largest US businesses are now pledging to rethink the purpose of their companies away from profit and towards ‘improving society’; and in the UK there are over 200 ‘B Corps’ similarly committed to giving equal weight to ‘planet, people and profit’. At the front line there are developments around ethical leadership in schools and calls for computer engineers and scientists to be required to take responsibility for the possible applications of their work .
By comparison the relative absence of any real debate on the place of ethics in adult social care is something that requires explanation. It may be that (like medicine and nursing) it is seen as a domain so suffused with ethical principles that any further introspection is unnecessary. At an intuitive level this is probably true in the sense that most people employed in the sector are doing the best they can in difficult circumstances. However the debate on the place of ethics in social care has to go deeper into the realms of ideology, policy and practice.
- Ideology: We have now had almost forty years of the incorporation of market values into traditionally non-market public sector domains – indeed adult social care was the canary in the ideological coal mine back in the early 1980s. This has not been an easy relationship for any of the parties and there is now good reason to question the place of ethics in the market model of service delivery.
- Policy: At the policy level the marketisation of social care provision has resulted in a sector that is fragmented and unstable – the regulator described it as being at ‘tipping point’ three years ago and contracts are now being routinely handed back to local authorities as companies either fold or choose to exit the market . Indeed, even the notorious Yellowhammer document detailing concerns about the impact of a No Deal Brexit identified significant consequences for what it described as ‘an already fragile market’ in adult social care. At the same time the trend is towards a concentration of ownership in larger companies many of whom are happy to increase dividend payments by loading their business with debt. This creates further uncertainty and threat of closure. The consequences of this are borne by those who use the services (who risk losing their support) and those working in them, who suffer poor terms and conditions of employment.
- Practice: The effect of all of this can too often be a complete or partial loss of moral compass at the front line. Some of the more publicised cases reveal such gross beaches of ethical behaviour that the transgressors are prosecuted – Winterbourne View, Whorlton Hall, Mendip House and Muckamore Abbey are just some of the recent examples. The more common breaches of front line ethical practice are things like lack of activities, insufficient time for eating, unduly long waits for help and the avoidance of difficult situations, as reported by Cooper and colleagues in their extensive survey of care homes.
What can be done about this? In posing the question we are essentially asking how ethical behaviour can be made more central to the way adult social care policy is formulated and services and support are delivered. A response would have three phases – understanding the inescapability of ethics; identifying ethical standards; and putting such standards into policy and practice.
The Inescapability of Ethics
Ethics is about the principles and values which, one way or another, guide our behaviour, our lives and the way we treat others. It is about questions of good and bad; right and wrong; just and unjust. It is hard to think of more fundamental matters than this, yet discussions on ethics and ethical behaviour in public life are surprisingly rare. On the few occasions that politicians acknowledge their place it tends to be in the context of distinct ‘moral dilemmas’ thought suitable for a vote of conscience, such as abortion, civil marriage and assisted dying. In reality the relationship between politics, public policy and ethics is much more intertwined. Ethical considerations are at the heart of what governments ought to do and ought not to do; they are central to the principles that should guide decision-making; they underpin how a problem is defined, how a response is shaped and how an evaluation is framed. In short, ethical neutrality by the state – or business – is not an option. The question then is not so much whether or not ethics should be at the heart of adult social care but rather upon making clear the ethical assumptions and principles upon which it is based.
Identifying Ethical Standards
Moving from the general to the specific is not straightforward but is essential – ethics has to be capable of application to practical situations. This was the Victorian tradition, for example with Bentham’s concern with prison reform and J S Mill’s campaign for women’s suffrage. In England the most notable attempt to address the place of ethics in public life has been the creation of the Committee on Standards in Public Life by the then Prime Minister, John Major, back in 1994. This led to the drafting of the seven principles of public life, now often referred to as the ‘Nolan Principles’: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. These provide a useful starting point but still leave out of the equation many other compelling ethical concepts such as respect, concern, responsibility, competence, trust, wisdom, kindness, justice, equity and service.
These sorts of considerations are already strongly entrenched in the academic literature on the ‘ethics of care’ and the vexed discussion on professional standards in social work that is currently underway in relation to the creation of Social Work England. This, however, leaves out of account a whole swathe of activity in the sector including those involved in commissioning, those working as social care workers and those shaping policy.
For a sector that originated with a moral mission there is surprisingly little discussion of the place of ethics in policy, planning, commissioning and practice in adult social care – indeed as Julia Unwin has forcefully argued in her Carnegie Trust monograph, kindness, emotions and human relationships tend to be the ‘blind spot’ in public policy. There is then an important consultation needing to be undertaken to develop a code of ethical practice and associated standards that applies to leaders, managers, commissioners, front-line staff and care providers. Such an exercise should breathe life into putting the humanity and dignity of others at the forefront and into the promotion of social justice.
Ethics in Policy and Practice
A consultation on ethical principles and standards will be meaningless unless it is both put into practice and shapes policy responses. In the case of social care workers this implies professionalisation and registration of the bulk of the workforce along the lines recently proposed by the All Party Parliamentary Group on Social Care – the position of those working as personal assistants and as small micro-providers may need separate consideration. In the case of care providers it means binding agreement to a code of ethical practice as a prerequisite to the award of contracts – the trade union, Unison, has already made progress on such a code and its adoption. And in the case of commissioning it implies professionalisation of the discipline and the application of inspection and regulation procedures that reflect and reinforce ethical approaches..
While all of these changes amongst commissioners, the workforce and providers are necessary, they will be insufficient without different policy responses. For too long we have had policies on adult social care that go against the grain of ethical principles rather than supporting them. A new model of adult social care needs to challenge the established paradigm of marketisation and consumerism – we have already moved too far from having a ‘market economy’ to being a ‘market society’. The contours of what this different approach might look like have been widely discussed and include:
- Risk-pooling as the underpinning principle for funding long-term care to overcome the current inequity and unfairness: This is based upon John Rawls ‘veil of ignorance’ argument – that in a situation where no one knows if they will need care and support it is in everyone’s interests that it is funded by a progressive taxation system to ensure it is there when needed. Meanwhile funding for local authorities should meet ethical standards of adequacy (sufficient to meet reasonable expectations of need being met) and equity (distribution of funding to the points of greatest need), neither of which are currently met.
- Public value as the guiding principle of commissioning: a much more robust version of the Public Services (Social Value) Act 2012, one in which the right to deliver public services would be dependent on the discharge of clear economic and social obligations.
- Co-production as the guiding principle underpinning the shape of services and support: a shift in power and control so that people who use services are actively involved in all aspects of designing, commissioning and delivering services.
- Self-determination: wherever possible people should have an entitlement to opportunities, respectful support, and the authority to exert control in their lives, to direct their services, and to act on their own behalf. The clearest application of this principle in adult social care is through attempts to personalise support and offer personal budgets.
- Valuing the Workforce: The bulk of expenditure in adult social care goes on the workforce and it is through a professional and ethically driven workforce that high quality support will be delivered. However the sector is characterised by low pay, insecure employment and low status, resulting in high turnover and a high vacancy rate. An ethical model would need to value and reward the workforce rather than see it as an asset to be ‘sweated’. This also has to encompass the informal workforce of carers, to protect them from unreasonable expectations – a resolution of the moral debate about the respective roles of the state, family and individuals.
- Commissioning Small and Local: There is evidence to suggest that those on the receiving end of services and support prefer a model that operates at what Fox calls ‘human scale’. The people most likely to design such arrangements are front-line workers and the people and communities with whom they work – the co-production principle in practice. This could, for example, involve commissioners being encouraged or required to prioritise the development of third sector organisations and community businesses to develop preventive support as happens in Wales under the 2014 Social Services and Wellbeing Act.
- Retaining Local Wealth: Adult social care is a big local business but much of the wealth created locally ends up elsewhere in the hands of national and international provider chains. A policy on local wealth retention would prioritise provision by local small and medium enterprises with strong ties to the locality. Some parts of the country are already demonstrating achievements along these lines, notably in Preston, Manchester, Barnsley.
- Legislation for Wellbeing: If ethics is important to policy-making it should be at the centre of public policy rather than the periphery. Some attempt is being made in Wales and Scotland to give the concept of ‘wellbeing’ a place in legislation. In England the concept of wellbeing – in principle – underpins the 2014 Care Act but this has been overwhelmed by austerity and is largely an aspiration rather than an outcome. Perhaps the most robust model is now underway in New Zealand where the principle is hardwired into budget allocations and there will be much to learn from this experience.
The case for explicitly putting ethical principles at the heart of policy and practice is not confined to adult social care – there is a wider loss of trust that requires some radical rethinking of the place of ethics in public and business life. Back in the 1980s adult social care was the first of the pillars of the post-war welfare state to be marketised and privatised, and few can be happy with the results. The time for a new paradigm is long overdue and whatever the details of this fresh approach it needs to based upon ethical principles, standards and outcomes.
Professor Bob Hudson,
Centre for Health Services Studies,
University of Kent