By Bob Hudson
It is looking increasingly likely that the government’s long awaited ‘solution’ for social care will consist of little more than tweaking with the floor and the cap of individuals’ contributions to their own care costs. If so, this will be a missed opportunity, but it will not end the campaign for a much broader rethink about how social care can improve people’s lives. In my new book Clients, Consumers or Citizens? The Privatisation of Adult Social Care I identify three essential steps to changing the conversation.
Reframing the Debate
The first step is to stop thinking about adult social care as being primarily about removing the fear of selling a house to pay for care in older age or of being a drain on the NHS. The more important question is one of what care and support should do and of how it needs to work. In this respect Social Care Futures itself has done much to shift the terms of debate with its emphasis on people of equal worth leading lives of value that they choose to lead as part of a reciprocal web of community-based support.
What this in turn raises is the question of how the reframing of an issue comes about. Johnson et al identify four stages in the process: innovation; local validation; diffusion; and general validation. It is hard to say exactly where the reframing of the adult social care discourse has reached in terms of these four stages. Research suggests public discourse is still narrow in understanding with representations of ageing, for example, largely negative. There is certainly much evidence of pockets of innovation and in some cases of local validation, but there remains much still to do before the final two stages could be said to have been reached.
Practical Improvement Support
Reframing the narrative needs practical support, some means of improvement capability among commissioners and providers. There is a great deal more of this capability in the NHS (especially the hospital sector) than in adult social care, which has never benefited from a fully developed programme to identify and share best practice. Fledgling bodies such as the Care Services Improvement Partnership, the Change Agent Team and the Integrated Care Network became early casualties of the Coalition Government’s ‘quango cull’ following the 2010 General Election.
Meanwhile the Care Quality Commission sees its role as primarily one of inspecting and regulating rather than supporting improvement through local relationship-building. This is a missed opportunity. A review of the impact of the CQC on provider performance emphasised the need for support, not just inspection and regulation. It urged the CQC to draw on its intelligence and insight to support providers, foster improvement and prioritise its use of resources. However, this conflation of inspecting and improvement roles is inherently contradictory and it is likely that improvement support is best delivered by a more trusted ‘critical friend’ along the lines of the Joint Improvement Team in Scotland.
Implicit in all of this is the idea that change needs to happen locally and at micro-level. The role at national level is to promote and facilitate local change, whereas currently local change movements are often fighting against the grain of national policy. Too often the problem is not so much a lack of innovation as finding ways for such approaches to take root more deeply in more places. Time, space and resources will be needed to breathe more life into better ways of thinking about service design and delivery, otherwise the established narrative around access, eligibility and service models will continue to dominate.
Challenging Established Power Bases
Change will ultimately, be dependent upon shifts around the social-structural context within which policy functions. This in turn requires thinking about where power lies in the policy-making process. In his classic analysis, Power: A Radical View, Steven Lukes distinguishes between ‘three faces of power’: issue, agenda and manipulation.
Issue: This is the ‘open face’ of power – the ability of one person or group to achieve compliance by openly making decisions that must be observed. In the case of parliamentary legislation there is at least some basis for this in implied democratic consent. It is here that the marketisation of adult social care has been built up through key policy landmarks such as the Griffiths’ Report of 1988 and the1990 NHS and Community Care Act. Any serious attempt to shift power towards people who need support, along with promoting alternative modes of sustaining people’s independence and wellbeing would require fresh legislation, not just discretionary ‘toolkits’..
Agenda: This is Lukes’ ‘secretive face’ – the power to set the agenda and make decisions behind closed doors; a situation where it is unclear who is making decisions and on what basis. This has increasingly become the modus operandi of adult social care decision-making where critical judgements are made without taking into account the needs, views and wishes of those most affected by them. This includes organisational decisions such as tightening eligibility criteria for accessing support; professional decisions, where front-line staff exercise discretion in how rules are interpreted and implemented; and business decisions where judgements on the terms and conditions of care workers, on loading a company with debt in order to extract dividends, and on whether or not to terminate market activity are decided in distant boardrooms. A new approach to adult social care would be based upon an ‘open’ not a ‘secret’ face.
Manipulation: This is the ‘deceptive face’ – the power to shape and shift values in such a way that the decisions that create benefit and advantage to the powerful party are accepted without serious questioning. In the case of adult social care there have been three decades to promote the concepts of markets, competition, choice and consumerism as self-evident virtues that require no further justification. Where defects in the model become apparent, these are then interpreted as failures of policy implementation rather than of misconceived policy design. The fact that the most heated policy debates are around funding by individual users of care rather than the model of commissioning and provision bears testimony to the force of manipulative power.
The most immediate way to bring about change is through the commissioning process. Many options exist; none of them are easy but all are achievable to some degree. Commissioning from local suppliers would redirect resources from national and transnational companies to local suppliers and populations. Commissioning small would give preferment to community businesses, not-for-profit organisations, to agencies with local roots, local presence and local accountability. Commissioning holistically would challenge the orthodoxy of separate organisations pursuing different and distinct objectives and place primacy on the importance of ‘place’ and belonging in people’s lives. Commissioning personally would replace the restrictive interpretation of a personal budget with a wider understanding based upon personal outcomes and supported, inclusive communities. And commissioning ethically would offer the opportunity to prioritise non-market values in decision making to support the social, economic and environmental wellbeing of an area.
The current mixed model is fundamentally flawed. Markets will go where there is money to be made; voluntary endeavour thrives most where people have the time and inclination to contribute; local authorities are commissioning hand-to-mouth; and communities are struggling to find the wherewithal to strengthen local bonds. Addressing this complexity will require political determination and excellence in statecraft, neither of which has been much in evidence for over fifty years. We are still in the foothills of change; tweaks to caps and floors are only a first step, but the journey continues.
Professor Bob Hudson, Visiting Professor in Public Policy, University of Kent