Disabling the care relationship?

A recent ruling has given encouragement to those demanding a better deal when it comes to social care for people with disabilities. According to The Guardian, from now on ‘councils must make it clearer to service users how a proposed care package would meet their eligible needs’. This is an important step, say campaigners, toward greater clarity about what care the disabled are entitled to; and a challenge to the operation of a much-maligned and clearly unfair ‘postcode lottery’. However, while this ruling is welcome, the care problem for people with disabilities runs so much deeper. The Winterbourne View scandal was one of the more disturbing examples of why concerns about cuts, funding formulas and assessments – while important – are not the most critical issues facing the care system today.

Notoriously ‘secretly filmed footage’ at a care home by BBC Panorama ‘appeared to show residents being pinned down, slapped, doused in water and taunted’. Rather understatedly one commentator argues that Winterbourne shows that we need ‘more dignified and suitable types of support’ for people with learning disabilities. Of course this is true. As it is for those working at the Remploy factories currently being closed down by the government.  According to lobbyists the problem is to do with the ‘large institutions’ charged with, and clearly failing to, provide care. The institutions that serve the learning disabled so badly need to be torn down. And yet scandals like Winterbourne suggest that something else very worrying is going on. The neglect and abuse of so-called ‘vulnerable’ people, in particular those with learning disabilities, is a problem associated with institutional care but it is not the institutions themselves that are to blame. While the problem of poor care standards has been recognised for some time in both the NHS and in the social care system; anxieties about abusive and neglectful care, mostly overblown, have tended to focus on informal and private arrangements in the community.

But more often than not it is formal, state-funded provision that is found wanting. Half of the health and social care settings visited by the Care Quality Commission (CQC) inspectors following Winterbourne were failing to meet minimum standards. But what does this mean? And what can a body like the CQC do about it? Impose more standards? It is the administering of care itself that is at the heart of the problem. As the chair of South Gloucestershire’s Safeguarding Adults Board put it, on publication of the serious case review, Winterbourne ‘should have been a safe place for them to be treated with care and compassion’. The particular institutional settings, no matter how old-fashioned or unpleasant, are secondary to the quality of the caring relationship. It is the institutional culture that matters most. Indeed, one might argue that the CQC is itself a part of the problem. Might it be that an overly-managerial and target-driven care system is just not conducive to the fostering of professionally compassionate relationships between carers and the cared for?

The disabled: the hardest hit?

As the Paralympics gets under way, I will be asking whether the disability rights movement can live up to the Paralympic spirit? Because It seems to me that far from encouraging people with disabilities to overcome the disadvantages they face, it has increasingly become little more than a variant of today’s stifling politics of pity. While there is much to complain about today, there is no problem so big that it can’t be made worse by the imperatives of competitive victimhood. There are no end of people claiming to be very badly done by, or should I say no end of campaigners and commentators claiming to speak on their behalf.

Whether its as victims of public sector cuts or the apparent excesses of capitalism, some are seemingly little more than the objects of other’s pity. This is particularly the case if you happen to have a disability. According to Brendan Barber, general secretary of the TUC: ‘No group of people is more affected by the government’s savage, ideological austerity than disabled workers.’ But it is not austerity that represents the biggest assault on people with disabilities. Rather it is the way that disabled people are portrayed by Barber and others that is most troubling of all. Not least by their supposed defenders. From the cuts to welfare to the closure of Remploy factories it is the disabled, we are told, who are the most pitiable. A high profile campaign organised by the Disability Benefits Consortium and the UK Disabled People’s Council leaves us in no doubt that they are The Hardest Hit.

Like I say, there is much to complain about. As Claudia Wood writes for Demos: ‘Disabled people are disproportionately reliant both on welfare benefits and public services’. Not only are 3.5 million people currently claiming cut-threatened disability-related benefits, Wood reminds us, many are also seeing the care services they rely on threatened by 28% cuts to local authority budgets. So the last thing I want to do is diminish the difficulties that people with disabilities are facing now more than ever. Quite the opposite. I will try to show over a series of blog posts here and in the Huffington Post, that it is only by challenging the diminishing of disabled people themselves, that the assault on their standard of living and on the quality of care they receive can be challenged.

Public managers should stop telling people how to behave

First published in The Guardian’s Public Sector Network

There is a fundamental contradiction at the heart of the public policyagenda today. While on the one hand we are urged to build a big society where citizens run things for themselves, on the other we are told to ‘nudge’ them in this or that direction and make decisions on their behalf.

Something odd has happened to public services over the past decade or so. Services that were once a part of the social settlement that led to the creation of the welfare state, have increasingly become a tool for telling people how to behave. Whether it’s creating better citizens or trying to change their lifestyles, the only question raised is how best to do it.

The government’s approach to recycling is to fund local initiatives rewarding good residents with points redeemable at local retailers. “We want to see people helping us to boost recycling rates by putting out their rubbish correctly,” said environment secretary Caroline Spelman as she launched a public consultation on the matter, “but bullying them with fines is not the way to do it.” Opponents, particularly local authorities none too keen on reverting to the weekly bin collection, only object that scarce public funds would be better spent on other behaviour-controlling initiatives such as the cuts-threatened SureStart centres.

The world of social care, while rhetorically in favour of more independence, choice and control, for its users, is obsessed with vetting the behaviour of staff, volunteers, or anybody else that might come into contact with a vulnerable child or adult. The NHS, of Olympic opening ceremony fame, may be free at the point of use. But no expense is spared on posters in GP surgeries and hospital waiting rooms telling patients that they must change their lifestyles – stop smoking, exercise more, lose weight – or to remind expectant mothers that ‘breast is best’.

Housing associations are as busy managing the lives of their tenants as they are managing the housing stock and more interested in building communities than building new homes. Schools apparently cater more to the contents of children’s school dinners and lunchboxes and managing misbehaviour in the classroom, than filling young people’s minds with something that might encourage them to sit still for a moment. Meanwhilea mass movement co-ordinator for the Olympic and Paralympic Games’ opening and closing ceremonies is apparently using dance – in consultation with the Metropolitan Police and the Criminal Justice Board – to reduce youth crime.

Indeed for those driving public policy today the delivery of public services is not the point. It is all about shaping new ‘active citizens’ the better to meet corporate objectives. But surely this gets things back to front? A truly active citizen acts of their own accord and not according to the imperatives of public management. The good news is that by ditching the policing of people’s behaviour we might emulate the vision of a big society in which responsible citizens take the reins. This is why we should adopt an alternative approach: one that genuinely enables people’s autonomy rather than smothering their initiative.

Who Cares?

First published in Huffington Post

Is there a crisis of compassion in health and social care? If the shocking scenes featured in Panorama’sUndercover: Elderly Care are anything to go by, the answer is surely yes. The interim report from the Commission on Improving Dignity in Care for Older People, the latest official response to various scandals in care homes and hospitals, suggests that this sort of thing is – if not widespread – then certainly more common than we might like to think.

As Alka Sehgal Cuthbert argued at a recent meeting of the Social Policy Forum, the report barely scratches the surface. She questions whether new improved national quality standards can make any difference. Such a managerial response is part of the problem not the solution, she suggests. Improving the so-called performance culture will do nothing to address what is going wrong with care. Indeed, if she is right, this sort of approach might make things worse by further undermining the caring ethos.

Instead Sehgal Cuthbert takes us back to first principles. We need to ask ‘what does it mean to care or be a caring person?’ she says. Those who work in the caring professions whether as a care worker, a nurse or – like her – a teacher, don’t necessarily have to even like those they care for. They have what my social worker colleagues like to refer to as a ‘duty of care’ to the people they work with. This relationship between carer and client is part of a wider web of relationships with strangers with which ‘we have a world in common’, she says. Or rather we would, it seems to me, if we weren’t so estranged from and suspicious of each other. As I have argued myself, we tend to exaggerate the extent of abuse in Britain, not only of older people, but of children and people with disabilities too. The fear-mongers have been crying wolf in this respect for so long, that some of us have had to hold in check our own scepticism this time around.

Could it be that these instances of neglect and abuse in care settings are a consequence not of inadequate procedures or the dark motives of unsavoury individuals coming into the profession; but of the very attempt to manage the perceived threat of neglect and abuse in the first place? Perhaps this is the lesson we should be learning. It doesn’t really matter how many supposed safeguards, regulations or vetting arrangements are put in place. They can’t make carers care. As Sehgal Cuthbert says, there is little point in the authorities deciding to ‘put empathy on the checklist’ too. It would be just one more thing to tick off the list. But how else do we go about addressing the crisis of care that she describes and that we keep hearing about? Shouldn’t we be doing something? How do we ensure that those we trust to look after our relatives when they are at their most vulnerable are not mistreating or abusing them? Should we just do nothing?

In a way, perhaps the answer is yes. In order for carers to care they need to be allowed the autonomy to act according to that combination of instinct and experience that allows them to fulfil their caring role. Not, that is, according to the criteria set by performance managers and regulators. This means carers debating the issue amongst themselves perhaps, and coming up with their own criteria for what it means to be a good carer. Logically enough this also means not relying on the Care Quality Commission or the Commission on Improving Dignity in Care for Older People to do it for them; and challenging not only poor care but those who undermine good care by promoting unfounded anxieties. Indeed if both Commissions were to, as it were, decommission themselves, carers might be able to get on with the business of caring, without having to worry about meeting their managerial requirements, and begin to embody the standards that society as a whole expects of them.

A riot of ill-informed commentary and impotent authority

You’ll be pleased to hear that I won’t be posting my views on the pros and cons of Payment By Results (PBR) in the social care sector. I’ll leave that for a quiet news day. Now that Cameron and Milliband have given their diagnoses – and Clegg has been acting improbably tough today – I have some belated comments of my own to make on recent events in London, Manchester and Birmingham. I will just say one thing, for those with an interest in social care. Oliver Letwin at that KPMG talk agreed that people using personal budgets are best placed to drive innovation in the sector. It is patronising to suggest that they lack mental capacity or need to be protected from their own decisions, simply because they use social care. I asked Letwin another question.

Surely the Open Public Services White Paper isn’t that radical. There is a good deal of continuity with over a decade’s worth of ‘modernisation’ under New Labour, isn’t there? He acknowledged it was in a ‘line of evolution’ with Blairite thinking on public services, and that the rhetoric bore a strong resemblance to that used by his predecessors. They too were all about promoting choice and empowering people. At least that’s what they said. But the coalition are much ‘more consistent’ and committed to ‘making it happen’ across public services. Whether you believe that or not, the fact remains that things have changed. It is not the case that the Tories have reverted to type as the headlines screamed following his speech. Far from it. The policies pursued by the coalition are remarkably similar to those pursued under the preceding New Labour governments.

And this is where I segue into the the riot of ill-informed commentary that has been doing such a bad job of getting to grips with something else that is quite new. For all the competing arguments used to explain the riots – and an opportunism from the likes of Ken Livingstone and Harriet Harman that was more than a match for the looters – it is this idea that nothing has really changed that predominates. Its the same old Tories doing the same old damage to the social fabric, they say. Which is the sort of thinking that gives trying to make sense of the rioters actions a bad name. Such a resorting to tired cliches is, after all, as pointless as the riots themselves. There is, nevertheless, an explanation to be had.

Two things can be said with some certainty. The riots of August 2011 were not a re-run of the riots of the 1980s. Though you wouldn’t think so given the censorious reaction to the usually insightful David Starkey, they had nothing to do with race this time around. Having said that, they did have something to do with the politics of multiculturalism – an ideological response to those earlier ‘race riots’ that has arguably contributed to today’s. Certainly, as Toby Young argues, moral relativism has a lot to answer for. And the second thing? The rioters weren’t reacting against state repression or police brutality, or anything else much. Quite the opposite. The impotence of the authorities – if we can still call them that – was exposed for all to see. As Mick Hume argues, the theatrical ‘fightback’ staged for the cameras, with raids on housing estates and the round-the-clock court sittings, didn’t make them look any more effectual.

So what other excuses have there been? The cuts, poverty and inequality, or a combination there-of have been cited ad nauseum. But as economic commentator Daniel Ben-Ami argues, these are long-standing features of capitalist societies, and people don’t ordinarily riot as a consequence. As for those who cite the evils of consumerism as somehow to blame, this is just an unhelpful ‘attack on aspiration’. In a similar vein, Brendan O’Neill, is irritated by those who seem to blame ‘neoliberalism’ and 80s-style greed for anything and everything, and now the riots:

… it is not Thatcher’s alleged cultivation of individualism and competition that nurtured the riots, but rather the welfare state’s decommissioning of those things, its silent war on working people’s social networks and self-respect.

Of course, there is also a problem with blaming the welfare state. Conservatives have been doing that for some time without lending any insights to the discussion. This post-war institution has, after all, been with us for 60-odd years – and has brought benefits (quite literally) as well as costs. However, as the sociologist Frank Furedi explains:

… in Britain the provision of welfare has mutated into a culture that encourages people to regard their circumstances as not a temporary phase but as a way of life. So the problem is not the provision of social benefits but the normalisation of welfare dependency as the defining feature of people’s life.

Which brings me back to where I started. The Tories have changed and not necessarily for the better. For all the talk of welfare reform and the ‘big society’, they are at least as implicated in the therapeutic-bent of today’s welfare policy as New Labour. As I discuss here. The culture of dependency was made tangible by the crisis afflicting the police, the proverbial red rag to a bull. But the crisis runs much deeper. Adult authority in general has collapsed. According to criminologist, Stuart Waiton:

From the top of society down there is a tendency to flatter, patronise and counsel the young as therapeutic, self-esteem focused techniques replace clear social and moral authority.

Dennis Hayes, co-author of The Dangerous Rise of Therapeutic Education, likens the riots to childish tantrums. Which wouldn’t have been so bad if they were stamped out rather than indulged. There were exceptions though. As Hayes argues, shopkeepers protecting their livelihoods and their neighbourhoods showed:

small signs of the possibility of a society where personal and collective responsibility begins to grow without the nanny state and its therapeutic institutions

Tessy Britton, author of Hand Made, is also encouraged by the sense of community to which the riots inadvertently gave rise:

The citizen-led clean-ups that happened across the effected areas in the days that followed the riots, lifted our spirits and gave us back a bit of hope that society hadn’t quite unravelled in the way much of the press seemed happy to promote.

And yet it would be naive to ignore the warning signs. As O’Neill makes clear, the reaction to Enfield’s vigilante ‘fascists’ puts official enthusiasm for this sort of thing in doubt. It seems that the powers-that-be are less than comfortable with community-building when the community starts building itself. But perhaps more importantly, as Furedi argues, there is a reluctance even to acknowledge the profundity of the ‘urban implosion‘ that the riots brought to the surface. And perhaps, after all, this is where the dysfunctional politics of social unrest and social care, respectively, might shed some light on the biggest problem of all. The politicians have, for some time, maintained a rhetorical commitment to putting people ‘in control’. But this is impossible while there is suspicion of the exercise of authority. Without it we are unable to truly take control of our lives and of the communities in which we live. Whether its a feeble culture of policing, or social worker aversion to ‘vulnerable’ adults making decisions about their own care – its time we put failing adult authority in the dock.