By Neil Crowther
#socialcarefuture has very deliberately focused on proposition, rather than protest. Our vision is of the future we want to be part of creating, not of the world we want to leave behind. But it is born of anger and frustration at the fact that this most ordinary and humble of aspirations – that people have the freedom and support to lead a life like everyone else – is regarded as extraordinary and continues to elude us. This gap represents the grave injustice being done to our families, friends and fellow citizens. In a recent article, Professor Tania Burchardt shared findings from research by Ipsos-MORI on unmet needs in social care, in which one respondent said “You don’t [cope], you exist. You just exist. It’s an existence. I’ll tell you what I think, I consider this house a coffin with a door.” That this gap is rarely expressed reflects the ‘soft bigotry of low expectations’ that characterises prejudice towards older and disabled people, and in turn towards the public services which, if better designed and supported, people could draw on to live their lives on an equal basis with others.
That in turn is why a positive vision, rooted in shared values, has to be our starting point. As the late Sir Bert Massie put it when Chair of the Disability Rights Commission ‘only high expectations will shine a light on injustice.’ Naming the harms caused by injustice is one thing. Stirring the ambition in people to rectify it is what really matters.
Under-funded and under-imagined
It’s also why the whole language of ‘fixing social care’ is so hopeless. It is rooted in and feeds these same low expectations. Rather than bringing to mind Elon Musk’s ambition to seed human civilisation on other planets, it tees up an image of people desperately trying to shovel seawater out of a sinking, creaky old boat. There is no ambition save to stop things getting worse. This is hardly an appealing idea for the public or for the Treasury.
Social care is not only under-funded, it is under-imagined. That’s why we need to ditch the language of ‘fixing’, which so limits this debate, and embrace the language of creating and innovating our way towards a future where everyone can live well.
The brownie, not the ingredients
What might that look and feel like beyond our headline vision? I’m told Ministers and officials are interested in three particular areas: funding, workforce and technology, so I’m going to focus on these. But first of all, I think we have to stop talking about ‘social care’ as our starting point. As the American pollster Frank Luntz advises in his book ‘Words that Work’:
‘Several years ago I asked Americans whether they would be prepared to pay extra taxes for ‘further law enforcement’ and 51% agreed. But when I asked then if they would pay higher taxes ‘to halt the rising crime rate’ 68% answered in the affirmative. The difference? Law enforcement is the process and therefore less popular while reducing crime is the desirably result. The language lesson: focus on results, not process’
Or as Anat Shenker-Osorio always advises – people buy the brownie, not the ingredients.
Our starting point when making the case for investment and reform should not be ‘social care’ it should be people living their lives well. As well as bringing the desired result to the front of the framing, and permitting us to talk about well-designed social care as the solution rather than the problem, this shift also creates the space to put across a range of different propositions. For example, many of us feel uneasy about the received wisdom of integrating social care and the NHS, but this is largely because social care is so often positioned and treated only as a pressure valve for the NHS, with the terrible consequences we saw during the pandemic. By making people living well the starting point, we can bring into view the role of care and support in attending to the social determinants of preventable ill-health. That way we might see integration not of social care into the NHS, but integration of thinking and investment in the things that keeps us well and away from acute services wherever possible, including the support to stay connected and do the things that matters to us, having enough resources to live decent lives in great places to live them.
From ‘funding’ social care to investing in good lives
Clearly government needs to begin increasing investment in wellbeing, starting now and incrementally increasing this investment over the coming years. But we should encourage it to adopt the broader conception of ‘resources’ that Hilary Cottam points to in her book ‘Radical Help’ and ask ‘how can we invest public money to unlock other resources and power to make change happen?’ There are so many exciting examples of this already happening, from organisations that prospect for and fuse together existing local resources, relationships and opportunities such as Local Area Coordinators, Community Circles and Community Catalysts, to people pooling resources and power such as Equal Care Coop in Halifax and the North West Care Coop. There are those helping to forge mutually nourishing connections across people and generations like Cares Family and Good Gym, while organisations led by disabled people such as Spectrum or Wiltshire Centre for Independent Living (to name but two) support people to draw on personal budgets to exercise control over their lives, building on their gifts, relationships and other assets, in order to engage meaningfully in the life of their communities. In the more regulated space, initiatives such as Shared Lives, Wellbeing Teams and Buurtzog put meaning, purpose and relationships centre stage. Meanwhile HousingLIN continues to push the boundaries of innovation, looking beyond residential care towards new, sustainable, models of housing and support. Put together, these approaches allow us to talk not about ‘spending’ on social care as pouring more and more water into a leaking bucket, but rather to bring to mind a metaphor of seeding and then nurturing ecosystems of formal and informal support that we can draw on to live the lives we have reason to value and which sustain our wellbeing.
From a ‘workforce plan’ to a ‘new deal for wellbeing’
If this is how we imagine wellbeing being supported, then what does that mean for ‘the workforce’ of the future? Well first of all I’m reminded of Charles Leadbetter’s two futures for personalisation, when he wrote:
‘Personalisation could be a sustaining innovation designed to make existing systems more personalised or it could be a disruptive innovation designed to put the users in the driving seat as designers and paymasters of services. It could be a programme to apply a lick of new paint to fading public services or it could be the harbinger of entirely new organisational logic.’
I make no secret of the fact that I would like it to be the latter, but believe to date it has more often amounted to the former. But I don’t think that is reason not to keep trying, and as I will set out below, I think digital transformation could provide the missing piece of the jigsaw.
If we adopt Leadbetter’s more radical view, it begs the question ‘who are the workforce’? Isn’t a barrier to going down the second path maintaining the idea that there are always ‘care workers’ and ‘people receiving care’. The latter need to be recognised as part of ‘production’ (or ‘co-production’) and have to be thought about as such, whether a person using a direct payment and becoming an employer, or someone re-purposing technologies to meet their own needs, or otherwise innovating in novel ways. They are not ‘being provided with a service’ or even accessing one, rather they are co-creating and commissioning their own support. While we have made some inroads, where I think we have wrong-stepped in the past is to see this in too individualised and commodified a way. The innovative models I outline above in the section on resourcing amount to the infrastructure that will allow more and more people to assume more responsibility for and control over their own support and their own lives. This is because our ability to form and sustain our identity and to be the author of our own lives is not in despite of the connections and relationships we enjoy, but contingent on the extent and strength of them.
Hence this shift to Leadbetter’s more radical proposition amounts, like with the idea of a ‘green new deal’, to lots of opportunities for creating new exciting jobs in a field fired by social innovation. Rather than some narrow conception of the ‘care-worker’, we might also be thinking about a wellbeing team coach, a circles facilitator, a community organiser, a resources prospector and negotiator, a smart home designer and engineer or a technology tailor. And yes, a social prescribing ‘link worker.’ But when we hear about a ‘workforce plan for social care’ is this what anyone has in mind at the moment? And if not, is that again because our ability to imagine the future is being coloured by low expectations and suffering a lack of imagination?
From ‘automating care’ to digital transformation
Though taking steps into the digitalisation, social care providers have proved to be somewhat immune to the digital transformation that is radically reshaping the wider world. Some might conclude this is positive, fearing as many do, that technology could strip care of its essential human qualities. But I don’t believe the answer is to resist technology. In the words of Nelson Mandela that is like knowing winter is coming but refusing to wear a sweater. Rather, we need to shape it, and make sure the future is one where technology is our servant, and we not its. If that risk sounds a bit dystopian, it’s worth recognising that the technology used by Deliveroo or Amazon to drive up productivity is already being used to track and monitor the performance of homecare workers, leading to rushed ‘care visits’ by low paid staff on zero hours contracts and no pay between them. This is technology driving down the quality of care and support, making delivering care no different to delivering a parcel or a takeaway meal, which in turn erodes the dignity of working in the field too.
However, in thinking about the chief risks of technology where social care is concerned, I sometimes think we focus on the wrong things and miss opportunities in the process. It’s often said that everyone expects more jobs to become automated but never their own, and in social care, people like to say that ‘the human touch’ will always trump technology. Certainly some technologies, especially robotics, are a long way off being able to supplant human support with things like eating, getting washed, taking medication and so on. But my bet is that, were such technology available and people able to bend it to their own will and preferences, many might actually prefer it over feeling reliant on other human beings, given the issues of power, status and dignity involved. I recall interviewing a woman in her early 70s – admittedly a tech enthusiast – who told me ‘when I need care, I want a smart home, a care robot and a self-driving care to take me to see my friends.’ If technology develops in a way that provides people with both objective and subjective autonomy, a stronger sense of dignity and perhaps most of all, more convenience, then it will – as it continues to do across different areas of our lives – take the place of human workers. I think we need only be fearful of this if we regard as acceptable the idea of paid care staff being people’s primary source of human company. If we don’t – and we really shouldn’t in my view – then technology can help free resources up to invest in the relationship-centred innovations I mention above, as well as (but not instead of) helping us to stay us in contact with one another, as we have all increasingly experienced over the past year.
So much potential is coming down the line. How will the internet of things revolutionise smart home technology? How will remote health monitoring and telemedicine allow us to stay living in the place we call home? How will brain-computer interfaces enable people with spinal cord injury to control more of the world around them? How will self-driving vehicles help us to stay connected? How are these questions guiding our thinking about the future?
For me though, the real prize is to harness the role that technology could play, and yet which it isn’t presently, to help realise Leadbetter’s more radical vision of personalisation. My generations digital footprint, and that of generations coming up behind me, is already so vast that it is feasible that it holds more clues to my will and preferences than anyone I know could express, or possibly that I could even understand or articulate myself. Imagine if we conceived of our digital footprint as a something to draw on in asserting our identity, will and preferences – as a central plank of supported decision making, especially should we reach a stage where we struggle to articulate this ourselves, or have no one else around available, able or willing to do so? Of course, there are ethical questions involved, but that is no reason not to consider them. Or imagine if platforms with the personalising algorithms of Facebook or Amazon were turned to supporting us to think about the lives we want to lead and how we might overcome barriers, design solutions and secure products and services? How about a ‘Pinterest’ for wellbeing, which, rather than full of ‘hacks’ for Ikea furniture was full of people sharing hacks for independent living? What if technology could overcome the things that put so many off direct payments, smoothing out the administration, handling the money, while optimising the choice and control? And imagine if all that could – as The Tribe Project is striving to by using machine learning – help shape a ‘wellbeing market’ genuinely informed by the hopes and imagination of people drawing on support and absent the dead hand of commissioners.
Reaching for the stars, not fixing a sinking ship
So there you have it, a vision not for funding, workforce and automation, but by starting with #socialcarefuture’s vision, for good lives, for investment to unlock resources, for social innovation and for technology centred on human wellbeing. Yes, the State needs to command the finances needed, but rather than it directly providing or commissioning services, it invests in – as Leadbetter put it – ‘a platform or an environment in which people take decisions about their lives in a different way.’ It should be a the chief investor in a shared long term framework to transform the way we organise the support that people can draw on to lead the lives they wish to lead.
If we care about the injustices of today, then let’s make our #socialcarefuture about a decade of investing in and unleashing creativity and innovation, not ‘fixing social care’. Let’s make it about reaching for the stars, not fixing a sinking ship.