Monthly Archives: October 2013

‘Big Society’ and the future of health and social care

Di Galpin

David Cameron suggests the Jubilee party was a ‘perfect example of ‘Big Society’.  Whilst it’s okay for a knees up, is it a suitable foundation for improving the quality of care  older people receive in Britain?

Unfortunately, David Cameron’s comments on Big Society do little to help us understand what “it” actually is, and to be honest, I am not even sure he  knows what it is beyond the usual sound bytes of ‘kitchen sink economic theory’*.  However, could the concept of Big Society actually have something to contribute to the debate on the future care of older people?

What is ‘Big Society’?

Big Society has been vilified as a return to the politics of the New Right,  a Trojan horse for smaller government,  and feted as the anatomy of the new politics  on which to establish the legitimate nature, and limits, of the relationship  between the  state and…

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If the care of older people is a national shame, why is govt not leading a national response?

There has been plenty of coherent and thoughtful responses to Jeremy Hunts comments on how we care for older people in this country, Mr Hunt would do well to read these as he might find them helpful.

The number of older people in residential care is minimal, especially since social care prioritizes supporting individuals to live at home, even if this does mean they might end up lonely, isolated and depressed, at least they are ‘independent’! There should be no one size fits all approach to the care of older people. Each is different, residential care for one might be a living hell but for another relief to unending loneliness. What is important is having a genuine choice and quality care.

However, older people can face even worse, many are maltreated and abused on a routine basis and this really does need to be addressed.

Having spent three and half years researching why the abuse and maltreatment of older people is so prevalent for my doctorate the one thing I have learnt is there are no easy answers. There really is no point in thinking we can return to a golden age where older people were valued and respected by families and wider society, I’m not convinced it ever existed, I’ve written on this before – read more here . Nor have I found this issue to be something specific to British culture. I’ve read research from around the world on the growing problem of “elder abuse” in both the developed and developing world. These have included, but are not limited to, America, Canada, New Zealand, Australia, India, Hong Kong, China (yes, China Mr Hunt),South Korea, Ireland, Sweden, South Africa and in Arab-Israeli communities. The maltreatment of older people is also widespread across Europe, including the UK, even in countries one might not expect, for example Italy where we have a romanticized notion of the stereotypical caring Italian family. The most surprising place for me to read of how older people are maltreated and abused was Tibet.

All the research suggests risk factors which increase the chances of older people being abused include being a female over the age of 85 years, suffering from cognitive impairment, poverty and isolation. In terms of who might perpetrate abuse and maltreatment, and where, it appears it can happen anywhere really, and anyone can be abusive i.e. family, formal and informal carers, strangers, friends.

Having discovered the abuse and maltreatment of older people appears to be a global phenomenon I have turned my attention to the question of what we can do about it. Since starting my research awareness of the issues older people face is now much more understood because of inquiries such as the Francis Review and numerous reports concerning care provision across both the residential and domiciliary sector from both public and private providers. There has also been a change of government, and a change in emphasis as the coalition clearly believe the protection and care of older people is everybody’s responsibility, in effect “Big Society”. Whilst I agree it is all of our responsibility, where I part company with this government is on its role.

Cameron and Co appear to believe an in-active state will stimulate and activate big society to take on more responsibility. However, this presupposes big society has failed in meeting its responsibility toward one another, and that we alone are the authors of our own destiny. I am not convinced it is this simple.

The legitimate role, and limits, of the state in individuals lives is ideological, and whilst this government seems to thinks by ensuring we have a small state big society will become the masters of their own destiny, in todays neo-liberal capitalist world I believe this is overly optimistic. We actually need leadership in Government and an active state to provide the conditions in which big society can thrive.

My research, so far, suggests state intervention could enhance older people’s experience of ageing in the future in 3 key areas. Firstly, the introduction of family friendly policies and work practices. Not unlike Sweden, Norway and Finland where a big state and big society work in partnership to combine a very strong economy with greater work/family life balance, equity and high standards of living for all where inter-generational support is achievable. This would help reduce social isolation and poverty, both of which are important because isolation and poverty increases the chances of poor outcomes for older people. Secondly, ethical, consistent and robust regulation of providers of services to older people. This is not limited to the provision of health and social care but also financial products such as pension/insurance schemes for example. Sadly an under regulated financial sector has led to many older people losing financial security. Again, with the link between poverty and abuse this is of major importance for older people in terms of protective factors in the future.

Lastly, and probably the area I feel most strongly about is a change in the values and ethics which underpin our understanding of care provision. Again, I have written on this frequently, the reconfiguration of care as a commodity, a product to bought and sold, a task to be completed demeans us all in how we view and express care. Care is increasingly viewed as a financial transaction where cost, affordability and profit are emphasised over care and compassion. The language of austerity has only served to harden our collective heart to older people as they are perceived as a financial drain on society. Linked to this final point is the issue of what we ‘want’ to afford as a society, I’m not convinced we cannot afford to fund a high quality system of care, is it more the case we do not want to because deep down we do not think investing in older people is of value?

It must be terrifying to be an older person today, old age is now more feared than death. Caring for older people should not be a task, a chore to be done, caring should simply be our way of being.

Families have stopped caring for older people…really? If only it was that simple Mr Hunt….

Jeremy Hunt suggests we need to renew the social contract between generations to support older people, has this ever existed though?

Many many families in the UK provide high levels of care and support for not only their older family members but also their adult children and grandchildren, is it really the case families have stopped caring. Commentators suggest given the complexity of family structures, their geographic proximity to one another, as well as to their places of work the relocation of responsibility for one another to a territorially defined neighborhood where communities come together with shared concern appears quite unrealistic in today’s society, especially since Ware also suggests ‘Real community activities are in decline‘ (2012, p. 89).

Hunt alludes to a return to previous patterns of care for older people based on a ‘golden age’, where older people lived in clearly defined neighborhoods within stable communities, and were consistently valued, respected and protected by family and the institutions that make up wider society. However, the World Health Organization (2002) suggest whilst traditionally family harmony has been assumed by governments in the care of older people, reinforced by philosophical traditions and public policy, the abuse and maltreatment of older people is actually a timeless phenomenon across the developed and developing world.

Was there ever a ‘golden age’ where older people were consistently valued, respected and protected by family and the institutions that make up wider society?

Although representations of old age and societal responses to older people have differed over time it could be argued old age has always been viewed as negative. In ancient Greece old age was portrayed as sad, with the Greeks love of beauty marginalizing the old. Although some commentators suggest the reality was more complex with the portrayal of older people in the classics as ‘both pejorative and complimentary’ (Thane, p.32). For Plato reverence toward old people was a guarantee of social and political stability, whereas Aristotle disagreed with such positive images. Cicero’s work De Senectute, written in 44 BC, points to the variety in individual experiences of ageing, acknowledging that for those who are poor and without mental capacity ageing is miserable, however, suggesting older people need to strive throughout their life to remain intellectually and physically able. This belief still underpins community care policy today in regards to older people.

Arguably one of the biggest flaws in the coalition’s approach to this issue is it does not appear to acknowledge its own role in supporting the negativity directed toward older people in its own use of discourse and language i.e. describing older people as a ‘demographic time bomb’ and ‘bed blockers’. This needs to be addressed.

This government is seeking to redefine the legitimate nature, and limitations, of the state in individuals lives. They appear to believe an in-active state will bring about the desired change in Big Society to take more responsibility for itself and others, however, arguably, this is built on a flawed understanding of the issues that face families today and the need for an active state to support families to support themselves.

From a European perspective research findings suggest older people’s experience of ageing in the UK falls behind that of many of its European counterparts, with the UK performing most poorly on indicators such as income, poverty and age discrimination (WRVS,2012).  The report states “the UK faces multiple challenges in providing older people with a positive experience of ageing, scoring poorly (although not always the worst) across every theme of the matrix” (WRVS, 2012, p.8).

 This provides a troubling vision of older people’s experience of ageing in the UK.

Older people’s experience of ageing in the UK can be improved, and it is all of our responsibility to try and achieve this.  However, we first need a coherent strategy to bring about the change desired by many who work with older people.  Government in the UK tend to address issues associated with an ageing population in individual ‘silos’.  Research from Europe suggests those countries taking a joined up approach where government consider how factors such as income, health, age discrimination and inclusion interact , the more successful policy approaches are likely to be to improve the experience of ageing.  However, any action needs first to take a long term approach and have a strong ethical foundation founded on a clear understanding of, and agreement to, promoting older peoples equality and human rights across the political divide.

As the BBC exposes problems in the “care industry”, I wonder should ‘care’ be viewed as an ‘industry’?

The BBC reported today on the experiences of two care workers, suggesting the ‘care industry’ is constrained by budgetary issues. All very interesting but probably not telling many in health and social care anything new, however, what I found fascinating was the taken for granted use of language in which care provision is conceptualised as part of an ‘industry’. Arguably, care is now perceived by government as a product, much like baked beans and ipads, only less regulated! Could the vision of care as a ‘product’ be part of the reason we keep going around in circles on this issue?

The industrialisation of care as a commodity to be bought and sold, and profited from, fully emerged under Margaret Thatcher and the community care reforms of the 1980’s and 1990’s. Such an approach is now so firmly embedded within the health and social care sector it is difficult for anyone to conceptualize care as anything other than a product where “value” is equated to cost rather than any sense of ethical practice or notions of compassion for one another.

Maybe it is time for a different approach.

Can we shift the emphasis on a ‘care industry’ to providing compassionate care?

Firstly, we do not know whether we have somehow ‘lost’ our compassion for others, or whether it has ever really existed. However, we do know that over the past few years ‘compassionate care’ is not something we can assume exists in the ‘care industry’. Whether the provider of care is from the public or private sector, we cannot take for granted that care will be provided with compassion, nor that individuals will be treated with dignity and respect.

So how do we ensure ‘compassion’ becomes the ‘norm’ in the provision of care, regardless of the setting and who is providing it?

Firstly, a change in approach from leaders across the sector, a change from a transactional style of leadership to one that is transformational. Transactional leadership is based on bureaucratic authority with an emphasis on task orientated goals. An organisation characterised by a transactional leadership fosters a management structure which leads to the development of a ‘defensive culture’ where members are expected to conform and follow rules without challenge.

However, transformational leadership is a process that motivates followers by appealing to higher ideals and moral values. Transformational leaders must be able to define and articulate a vision for their organisations, and the followers must accept the credibility of the leader. Organisations characterised by transformational leadership are more likely to have a ‘constructive culture’ where members experience constructive cultural norms, for example, organisations set challenging but realistic goals and manage in a participative manner where relationships are constructive and open so as to achieve agreed goals. This is not to suggest transactional management is not also required in some measure, however, the transactional approach seems to have carried greater emphasis across health and social care. This has been my experience working in the public sector.

An ethos of an organisation comes from the top, an ethic of care informing leadership and management practice would make a huge difference. You just have to think about the ethos of where you work to think about how it affects you in your day to day work. It’s no different on a hospital ward, a private care home or in a care agency.

My feeling is the care sector requires inspirational leadership. Arguably the “care industry” is over managed and under led at present. There is a difference between leadership and management, although, both are required, but leaders are central to how their managers perform. When I think of a ‘good’ leader I think of people like Gandhi or Lincoln, people who are humane, humble, who inspire you to engage, to strive to achieve change for the greater good. They have a grand vision, and not a vision solely focused on targets and value for money, but higher values, such as compassion, dignity and respect is their motivation. The type of values that are the foundation stones of a humane care system.

Another key factor, I feel, involves ensuring the right people are in the workforce – we have to ask are we recruiting the right people into the care sector, whether as carers, leaders or managers? Clearly there are many good carers/leaders/managers out there, but we need a lot more, however, this has to be based on suitability not availability. On the ‘frontline’ care providers, whether public or private, have had real difficulty in attracting people into the workforce. This is not surprising when you consider how government and wider society not only undervalue such jobs, but also those being cared for, with the vulnerable being marginalised in society for being, well, vulnerable and in need of care!

Caring for people is a demanding, and rewarding job, but, carries little status and is seen as something ‘anyone’ can do. Believe me it is not. From my professional experience I’d say the best front line carers are those who have a deeply ingrained respect for others, and who genuinely like people. This is not something that can be taught, but they are the characteristics required to develop a professional, and caring, workforce. Recruitment of the right people, along with high quality support and training and descent pay and working conditions are central to turning the system around. However, already I hear the voices out there ‘how do we afford this’? Arguably we have to afford it if we really want change.

Where our vision of care does not extend beyond a discourse of free markets and cost, a strong philosophical, moral, and ethical framework maybe required to guide the provision of care. For care to become more than a commodity reform is required at a structural and individual level, founded on a new discourse that emphasises dignity over price, compassion over cost.

We are at a moment in history where society is questioning our whole economic system. Whilst it has brought much in terms of material resources for some, the cost at a moral, ethical and philosophical level in the “care industry” leaves a lot to be desired, maybe it is time to say care is too valuable to be classed as a commodity.

5 or 15 minute care visits? My cat receives better care!

I wrote this over a year ago, now the issue is 5 minute visits!

I enjoyed a weekend in Cornwall recently, as per usual we had to make arrangements for Barney (our 18yr old tabby with two pinned hips and one blind eye). We use a fantastic agency who come in and not only feed him but spend time with him, each visit is about 45 minutes long to ensure there is time for a bit of pampering. On our return we read about Barney’s exploits since we have been away telling us how he has been. If only the care of humans was as advanced!

The focus on 15 minute visits masks a fundamental problem with the direction of travel in the provision of health and social today. Care is not a commodity to be bought and sold like any other, therefore business practices that are currently framing their commissioning and delivery are not appropriate. Issues around zero hours contracts, travelling time for carers and low wages need to be addressed. If we are unable to treat those who provide care decently how do we expect those who use services to be viewed as more than a consumer of a ‘product’?

Care should not be viewed as a unit to be delivered, care is all about compassion, dignity, respect and integrity. Until we grasp this nothing will change. I am sure there are many out there who can only dream of receiving the same level of care as Barney, shouldn’t we really begin to re-focus our energies into developing a system of care that is actually caring?

(p.s In case you are wondering how much Barney’s care costs, £7.50 per visit)