Social Care for Free Citizens

A Manifesto Club Thinkpiece

In short…

Social care should support people’s autonomy and independence, allowing us to control our lives as much as possible.

The allocation of personal budgets for people to spend as they see fit is a step in the right direction.

However, the pervasive culture of suspicion which tries to nudge people to make the ‘right’ choices must be challenged.

We should not give in to the tendency to see the potential for abuse at every turn, especially when dealing with society’s most vulnerable.

Social care for free citizens must begin by defending people’s ability to choose for themselves.

The ‘personalisation’ of social care is a good example of how today’s public services can liberate people rather than simply control them. One study estimates that ‘within the next five years, 1.5 million people could be using personal budgets to commission and manage their own support.’ [1] Promoting people’s independence, choice and control (as the rhetoric goes) points the way forwards towards establishing a more fair and just social care system. It ultimately shows how a new public sector ethos can aid the creation of a society of free citizens.

It seems the public service revolution is already underway. The government is dedicated to developing a personalised welfare state. The Conservatives similarly want to allow people to spend the money allocated for their care as they see fit, and ‘give some of our most deprived citizens the opportunity to live independent and fulfilling lives.’ [2]

Indeed, it is partly the endorsement of conservative critics that lends weight to the suspicion that ‘personalisation’ is a slippery term used to disguise public services cuts and get tough on benefit claimants. Yet, despite this not entirely unreasonable nervousness, I have found myself warming to the idea.

This Thinkpiece constitutes an argument for a social care policy that truly supports people’s autonomy. We should challenge the fretful desire to nudge people into making the ‘right’ choices and impede people from truly taking control of their lives, and support a genuine personalisation of social services.

A truly active society

There is a sympathy between personalised social care and a personalised welfare system: each can help people play a more active role in society. Indeed, the idea of personalisation is most developed in the field of social care for adults, but has much wider implications for the delivery of a variety of public services.

It is true that in the current economic climate and amidst unprecedented levels of welfare dependency (real and rhetorical), political parties agree that personalisation is a good way forward. Yet whilst the economic recession is not something to be welcomed, it does present a profound challenge to the way we organise public services. It forces us to consider as a society what we, both as individuals and in our communities, can do for ourselves — and what we need from government.

The current government has its own idea of what personalisation might mean. As the Prime Minister puts it in his foreword to Putting the Frontline First: Smarter Government, personalisation means creating ‘services that are universal to all but personal to each’ and that ‘strengthen the role of citizens and civic society.’

Indeed, there is a good deal of confusion about the role of the state in our lives today. The fundamental question of when it is appropriate for the state to intervene in our lives is not even being asked, never mind answered. Despite talk of handing over control to people, whether by co-production, co-operatives or user-led organisations, there is a tendency for political parties to offer us ‘support’ whether we like it or not.

So, whilst we will soon see the introduction of personal health budgets, the prevailing health care culture has done little to promote people truly taking control of their lives. Attempts to shape people’s behaviour and nudge them towards making the ‘right choices’ about how much they drink, eat or smoke doesn’t bode well for those of us who want to help people make their own decisions – whether they are ultimately good or bad for them, and whether we like it or not.

That is a reason why these reforms are so badly needed. They could, if developed in the right way, encourage a welcome shift in our expectations of ourselves, and each other.

No suspicion

A headline early last year claimed ‘Over 50% of carers admit to elder abuse’. [3] It was based on a study which concludes that instead of suspecting paid carers of abusing older people, authorities should address the ‘taboo’ of abuse carried out by family members. However, those caring for elderly relatives with dementia were not physically beating their relatives. They were mostly shouting at them. The scary 50% in the headline was 50% of just 220 carers interviewed. A further one third admitted inflicting what they describe as ‘significant levels of abuse’ but the term ‘significant’ here was taken to mean ‘swearing often or being insulting’. Not nice maybe, but not abuse either.

This and similar studies regularly get picked up by the media, generating considerable anxiety about something that we, not least those doing the research, can only speculate about, giving legitimacy to whatever interventions are deemed necessary.

Even if those convinced we live in an abusive society concede people are not regularly beating up their grandparents, they are nevertheless, we are told, financially abusing them. Levels of theft and fraud affect ‘hundreds of thousands of older people’ involving ‘tens of millions of pounds’, according to Action on Elder Abuse. [4]

While there are no doubt instances of financial and elder abuse, although neither term is particularly helpful, these wider claims need to be challenged. Why, despite an apparent lack of evidence to support the view, are we told that elder abuse is widespread? I can only assume that those who make these claims see human relationships as inherently abusive.

The truth is that no matter how vulnerable an older person, it would be wrong to build our approach to safeguarding on a presumption of harm and vulnerability. Doing so would likely undermine those relationships with family, friends and neighbours on which so-called vulnerable adults rely.

And yet passing of the Safeguarding Vulnerable Groups Act in 2006 and setting up the Independent Safeguarding Authority to oversee the new vetting and barring arrangements, has given legislative and institutional form to the notion that we’re all vulnerable now.

Fewer safeguards

Nevertheless, responses to the consultation on the government’s adult safeguarding guidance, No Secrets, do suggest there is some concern about these developments. The use of the terms ‘vulnerable adult’ and ‘abuse’ has been questioned. There is an unease about the implicit robbing people of the dignity of being an ‘adult’, and a concern that what we really need is more support rather than suspicion of those who care for their elderly relatives.

The fact there ‘were reportedly few successful prosecutions in relation to safeguarding’, as the police responded, should be reason for optimism, not cause for alarm as lobbyists would have us believe. It suggests that elder abuse and financial abuse may be much less prevalent than we are being led to believe.

There is something of a stand-off between safeguarding and personalisation, between choice and risk. And yet there is a clear feeling from those who use services that ‘safeguarding decisions should be taken by the individual concerned’ and that ‘they wanted to retain control and make their own choices’. Too often, we learn, safeguarding is ‘experienced as safety at the expense of other qualities of life, such as self determination and the right to family life.’ [5]

While safeguards are an important consideration for those of us working with people with disabilities, mental health problems or people who may be ill or frail, the risk-averse response of the authorities is out of all proportion to the actual (and thankfully rare) incidence of abuse itself. Too often seeking to protect ‘vulnerable’ people from risk is to protect them from life itself and all it brings, both good and bad.

The proliferation of paper exercises may make us sleep safer in our beds, but there is little evidence that risk assessment matrices and safeguarding procedures do anything to prevent things going badly wrong in practice. Indeed, while these tools may have a role to play, they can also generate false positives and a wider sense of anxiety. Relying on them can only distract and inhibit care workers, keeping them from the business of caring and making it more difficult to spot abuse in those exceptional cases where it arises.

Instead of generating safeguarding referrals by promoting ‘awareness’, which seems the perverse dynamic currently at work in local authorities up and down the land; we should be generating local intelligence about the outcomes of those referrals. We should work out the real and often mundane risks people might face, such as the risk of falls for older people living alone or the risks presented by unscrupulous traders known to be operating in the local area. This is the only rational way to respond to what we actually don’t and can’t know in advance.

Taking control

As David Brindle argues in The Guardian, ‘Social care has to its surprise turned up in the vanguard of public services reform through personalisation, blazing a trail for other sectors that are now gingerly following suit.’ [6] For Charles Leadbeater (the academic most associated with the idea), personalisation is a way ‘to mobilise service users’ intelligence to find lower-cost ways to improve services.’ [7]

In a sense, the personalisation of social care takes the Community Care reforms of the 1980s to their logical conclusion. At the time, reformers were accused of putting vulnerable people (and the public) at risk, using kindly sounding rhetoric as cover for cutting services. There was some truth in this, and yet reforms helped to get ‘vulnerable’ people out of institutional care and into the community. Likewise, where local authorities are beginning to implement these changes, there are examples of how people are being given the opportunity to escape the confines of traditional services, and find better, more tailored solutions to the problems they face in their day-to-day lives.

For instance, in 2005, Cambridgeshire County Council piloted self-directed-support in their learning disabilities service. [8] By 2008, 56 of their service users were in receipt of personal budgets. In their evaluation they found people tended to spend their money on leisure pursuits, personal assistants and help at home more than anything else.

Alan, a young man with Down’s syndrome, ‘has taken up running, including completing a half-marathon, and swims at the local pool three times a week’. His mother manages his budget for him, and ‘with Alan, recruits his personal assistants’.

Alice, keen to avoid a residential or supported living arrangement, and wanting to stay close to family and friends, used her budget to pay for a place of her own under a shared ownership scheme. With her family, she arranged for a local organisation that specialised in mortgages for people with disabilities, to sort things out for her. According to the sister of Dev, a young disabled man who didn’t go out at all until his family were given control of his care, he now gets support and ‘goes out horse riding, swimming and for regular walks’. It has, she says ‘improved his quality of life immensely’, and that of his family.

The London Borough of Richmond upon Thames found that while a quarter of the service users they interviewed continued to use traditional services (ie. day care and residential care), a third paid friends and family members to support them, and half paid for transport. By far the most common use of personal budgets amongst this group of service users was for paying for help in the home, for carers and personal assistants.

One of their disabled residents, Anna, who left her teaching job to have a baby, says ‘I couldn’t even go to mother and baby groups because I needed someone else to carry my daughter when she was a baby or to help me with a pram. Just knowing I can pay someone to come with me and help me makes a big difference.’ Instead of feeling ‘trapped and resentful’ toward the limitations imposed by her disability, she is now able find new ways of dealing with old problems.

The personalisation of social care has something going for it precisely because it is at odds with so much else that officialdom does these days. It goes against the intrusive, paternalistic grain – but we also need to be on our guard. For all that personalisation promises, many enthusiasts seem oblivious to the counter-trends that threaten to undermine these changes.

Historically, on the political right, says Ken Mclaughlin, an academic and former social worker, social work has been understood as creating a dependency on welfare. On the radical left as doing ‘nothing more than supervise the deterioration of people’s lives.’ He argues that we need to understand people as capable of change.

This is something which even enthusiasts for personalisation seem to struggle with at times. They call for supporting people when they take ‘positive’ risks, but this is a misnomer. There is no getting around the fact that as we ‘allow’ people to take risks they will also have to face the consequences. But in most cases the benefits of ‘vulnerable’ people taking control of their lives far exceed the problems that come with that newfound autonomy.

We have an opportunity to renegotiate where the line is, to dispute the safety-first suspicion of events behind closed doors and assert people’s right to make their own decisions and control their own lives. Otherwise, these reforms will only be neutered by the powerful presumption of harm.

Some social workers regard personalisation as the realisation of their core values, as an opportunity to help people live their lives as normally as possible. This is not to deny the public servant’s duty of care, or the need to protect those who are genuinely vulnerable or lack capacity. It is to underline where it is legitimate for them to act on that duty of care and where it is not, or (put another way) to have a wider view of what that duty entails.

Social workers should be seeking solidarity with the people they work with. When a service user’s personal autonomy is hindered, this is at least in part a consequence of the barriers put in the way when workers could be using their discretion to support people where they need it, and to liberate them where they don’t from the dispiriting experience of dependency.

Genuine personalisation

We cannot expect the personalisation philosophy to win out on its own. Personalisation and the choice agenda more broadly have limits. The world cannot simply be reduced to our individual choices.

Our current culture undermines personal freedoms in so many ways, and is already threatening to undermine the promise of personalisation. Fears about the potential for abuse hang over debates about how we look after society’s most vulnerable. The prospect of people taking control of their budgets and choosing who to commission services from only heightens these fears. It provokes more prevention strategies, risk assessments, concerns about service users’ mental capacity, and possible ‘financial abuse’ from door-steppers and family members alike.

This is why it is important to join in what the Prime Minister recently described as the ‘biggest debate we have ever had on the future of our care system.’ [9] Having said that, despite the pre-election bickering about free personal care and funding of the proposed National Care Service, there is a broad consensus that social care (like welfare) needs reforming.

Most agree what those reforms should look like too; there should be a shift to prevention and early intervention, and an extension of choice and control for individuals, they say. And yet it is this pre-emptive aspect of the transformation of adult social care that, until recently at least, has been overshadowed by the controversy over the personalisation of services.

The worry of early intervention

The problem – in adult social care at least – is not early intervention or preventative strategies per se but the broader climate of anxiety, stoked by the proliferation of abuse scandals, in which they take place.

It is this wider culture that is such a formidable opponent for those of us who want to give so-called vulnerable people greater control over their lives. As the obsession with vetting, checks and databases makes all too clear, this isn’t just a case of changing the culture in social services; it is about challenging the assumptions held across society but given credence by politicians, commentators and policy makers.

The notion that if somebody develops dementia our first instinct should be to suspect the family of pinching their money or abusing them is despicable. But, it is the logical conclusion of an indiscriminate culture that brands us all as potential abusers, and the cared-for as potentially lacking the capacity to live their lives without official interference.

While early intervention, as an argument for more cost-effective public services and a way of avoiding long term dependency, has a lot going for it, the rhetoric of early intervention in relation to safeguarding is far more problematic, and threatens to derail reforms that have real promise for people who use social care services. There is an undeniable logic to the notion that professionals should ‘work together’ and intervene early to prevent neglect or abuse.

But we cannot know in advance what goes on ‘behind closed doors’. Sometimes we can do more harm than good by intervening. And sometimes the assumptions that underlie interventions in people’s lives are themselves problematic.

In practice, early intervention can mean an over-reliance on databases, on checks and procedures, rather than the good practice and judgement of social workers and other professionals. It can mean an obsession with ‘awareness’ campaigns and generating referrals, rather than responding to known risks in the community. This is a consequence of a culture that tends to exaggerate the extent of society’s problems. In reality, social services (and all of the other agencies involved in safeguarding) can only play a limited role in protecting people from abuse or neglect. It is primarily the role of the wider community to look after the welfare of its members.

In so many ways, we cannot afford to continue making these interventions in people’s lives. The challenge is to trust communities to get on with things, to recognise that even the most vulnerable are actually quite robust and able, and unlikely to come to significant harm; to build services that are more limited in their remit and yet more effective in their role, by focusing on supporting good practice and only making proportionate interventions.

The only way to transcend our culture of dependency is to launch a more wide-ranging assault on those who would hold people back ‘for their own good’. So yes, we need to reform our care and welfare systems to really give people the opportunity to eject the state from their lives, but we need to do more than that.

If the system is to be truly transformed and have a real impact on individuals, their families and the communities of which they are a part; then people must be able to live their lives as they see fit, and have real control over the support that they receive. Such an outlook requires we challenge the exaggerated sense of people’s vulnerability and irrational fears and prejudices about what happens when they are left to their own devices. We need to make the rhetoric of empowerment and choice meaningful by rediscovering a sense of people as autonomous and able citizens, not as dependents on an over-protective and intrusive state.

In summary, it is only by reorienting our relationship with, and our view of, ourselves as makers of our own destinies, rather than as victims of circumstance – that we can begin to open up wider possibilities for the transformation of our lives, not just the transformation of the services we receive.

We need to stop standing in people’s way, and advocate a public service model that is conducive to promoting a sense of ourselves as autonomous and robust individuals. It may seem modest in the wider scheme of things, but there is nothing more radical today than to stand up for people’s personal freedoms and to defend their capacity to run their own lives, whatever disadvantages they face.

 

Endnotes

[1] http://www.demos.co.uk/publications/at-yourservice

[2] The Conservative Party, Work for Welfare, 2008

[3] http://www.guardian.co.uk/society/2009/jan/23/

elder-abuse-dementia

[4] http://news.bbc.co.uk/1/hi/business/7601419.stm

[5] http://www.dh.gov.uk/en/Consultations/

Responsestoconsultations/DH_102764

[6] http://www.guardian.co.uk/world/2009/dec/16/

public-services-policy-review-decade

[7] http://www.guardian.co.uk/society/

joepublic/2009/dec/16/ways-to-protect-publicservices

[8] See: http://www.in-control.org.uk/

[9] http://www.number10.gov.uk/Page22402

http://www.manifestoclub.com/files/DavidClements01.pdf

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