Monthly Archives: October 2018

A green paper on social care funding that spells disaster and a compassionless future for us all…….

The delayed  Green Paper on the future of social care suggests we need a scheme to pay into for our care, of course we already have this in place now where everyone is covered,  but of course govt means a private company insurance scheme, a for profit scheme. The Kings Fund suggest The Health Secretary, Matt Hancock, is attracted to the idea of an ‘opt-out’ insurance scheme for social care costs. Workers would be automatically enrolled and would then be protected against future costs of care (either all costs or, if the scheme had a lower premium, just against catastrophic costs). People could opt out but, if they did, they would need to cover their future social care costs themselves. Indeed, and how might that work Mr Hancock?

What an imaginative neoliberal idea,  after all the privatisation of social care has gone so well, what could possibly go wrong ……….

The lack of imagination shown by successive leaders in health and social care knows no bounds. Not only does it do a dis-service to wider society they have created a discourse on care wholly focused on cost rather than values such as compassion and respect. Whether it is children or adult services our leaders continue to focus on framing care as a commodity in which the balance sheet and short term savings are the priority. Yet we know the care ‘industry’ is failing us.

In children and family services Professor Eileen Munro has rightly highlighted the ‘fickleness and failings’ of the market, suggesting caution in establishing a market in child protection which could create perverse incentives for private companies. A  headline last year highlights the less savoury side of outsourcing – ‘Now troubled children are an investment opportunity: 18% return on the most disturbed and needy children in care homes is the extreme end of Britain’s outsourcing culture’ (Polly Toynbee)

Over three years ago the King’s Fund highlighted what many in the sector already know, the free market is failing, stating

‘Social Care is now a complex and sprawling sector – more than 12,000 independent organisations, ranging from big corporate chains to small family-run businesses, charities and social enterprises, which makes the NHS provider landscape look like a sea of organisational tranquillity. Less than 10 per cent of social care is actually provided by councils or the NHS – their retreat from long term care provision is virtually complete. But unlike the NHS, when a social care provider hits the financial rocks, bankruptcy not bail-out is the more likely scenario. But a deeper problem is the failure to think through the consequences of shifting the bulk of our care provision to a private business model’.

It is time to move beyond the ‘outsourcing’ of care, where arguably vulnerable children and adults are exploited for profit. Have we forgotten the experience of the vulnerable patients of Winterbourne View Hospital. A hospital set up by a Swiss equity company who primarily saw it as an investment opportunity and when the abuse of its’ patients was exposed promptly closed it down, probably moving onto the next investment opportunity provided by this government in the outsourcing of services.

Sadly government chooses to ignore this aspect of outsourcing.

The issue with ‘outsourcing’  is ideological, aligned as it is with  neoliberalism which has nothing to do with principles, values and ethics that should underpin care. At its most basic outsourcing is about profit being made from the lives of those most vulnerable in society.  A report published last year by Lancaster University entitled ‘A Trade in People’ expresses this clearly when writing

‘it is clear to us that the way in which the healthcare economy has been encouraged to develop by recent governments turns people into commodities and liabilities. For local authorities and CCGs they are liabilities that they have often sought to export to other areas and for independent hospitals they are a commodity and source of millions of pounds of income and profit.’

Nobel prize winning economist Joseph Stiglitz is clear, we are now engaged in a battle which is ideological, describing free market neo-liberalism as a stifling economic ideology which has run it course.

Neoliberalism has an insidious presence in our lives, much like the air that we breathe, everywhere, yet unseen. George Monbiot provides a compelling argument against this ideology, which values the free market as the place in which citizens can exercise their democratic choices through consumer choice and the private provision of goods and services. Supporters of neoliberalism maintain “the market” delivers benefits that could never be achieved by government, and that the more unregulated the market, the better the efficiency.

Within this framework everything we do, and every person is a potential commodity that can bought, sold and traded for profit. What a world to live in.

Michael Sandel argues the free market is not just a mere mechanism designed to deliver goods, it also embodies certain values, and the problem is these values ‘crowd’ out non market values which are really worth caring about and preserving, such as compassion’.

Please leaders of this country, whatever your political persuasion, be imaginative, be brave, be bold, but most of all be compassionate.

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The ambiguity of ‘evidence based practice’

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Di Galpin

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Uncertainty is an inevitable aspect of social work practice, yet, the creation of certainty is a fundamental tendency of the human mind, and it is not just our perceptual system which automatically seeks to transform uncertainty into certainty. Government and wider society demand a high level of certainty from social workers, especially following high profile tragedies, and subsequent reports identifying ‘failings’ in practice. As a response to such ‘failings’ the concept of ‘evidence based practice’ (EBP) has proliferated in social work.

EBP is presented as a model of critical appraisal, designed to inform practice, where the practitioner has…

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The ambiguity of ‘evidence based practice’

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve?

Uncertainty is an inevitable aspect of social work practice, yet, the creation of certainty is a fundamental tendency of the human mind, and it is not just our perceptual system which automatically seeks to transform uncertainty into certainty. Government and wider society demand a high level of certainty from social workers, especially following high profile tragedies, and subsequent reports identifying ‘failings’ in practice. As a response to such ‘failings’ the concept of ‘evidence based practice’ (EBP) has proliferated in social work.

EBP is presented as a model of critical appraisal, designed to inform practice, where the practitioner has a relatively autonomous role in searching for, and critically analysing, research evidence to inform their decision making. The latest guidance on the refreshed PCF articulates this commitment once again, and adds an additional expectation that social workers also generate ‘evidence’ to inform practice.

‘More reference throughout to importance of evidence and evidence-informed practice and the inclusion of more reference to ‘evaluation’ alongside ‘research as key source of evidence and engagement of practitioners in evidence/knowledge generation.‘ (BASW,2018)

Whilst practitioners and educators strive to adhere to this principle it could be argued as a ‘professional capability’ this ignores the complexity associated with notions of EBP at both a practical and philosophical level.

Is EBP at odds with real work social work?

Practitioners across allied professional groups are constantly called upon to manage uncertainty, ambiguity and complexity where there often seems to be a plurality of ways to understand what is happening in practice contexts.

From a philosophical perspective EBP appears to operate on modernist foundations.  For example seeking to adhere to methodological and analytic standards of rigour, which demonstrate the reliability of a scientific approach, because this will provide clarity in establishing the ‘right’ evidence is combined to create systematic and cohesive frameworks of knowledge. The belief that by adopting this approach one can achieve a level of certainty is alluring, yet, arguably, unrealistic in social work practice, and indeed may lead practitioners into a false sense of security when making decisions based on EBP.

Postmodernist frameworks are of benefit here to thinking about the multiple discourses at play in social work practices, and understandings the dynamics between them – particularly concerning power. This includes shifting from singular forms of objective understanding, to consider the diversity of subjective knowledges at play in practice contexts. This requires practitioner and academics to appreciate how objective knowledge is a contested concept which can lead to a fruitless search in complex situations for certainties that may not exist.

Peshkin (1988) provides an interesting perspective which extends, and troubles, the notion of objectivity by suggesting the ‘taboo’ of subjectivity stems from a misunderstanding of its potential role in EBP. It is our own subjective involvement in practice—not the precise replication of the event—which can provide strong theoretical insight. However, we are somewhat conditioned as practitioners and academics to see subjectivity as a ‘contaminant’. Yet, that contaminant is always present, one can never get away from one self. As Alan Peshkin eloquently reminds us

“Whatever the substance of one’s persuasions at a given point, one’s subjectivity is like a garment that cannot be removed. It is insistently present in both the research and non-research aspects of our life. … our subjectivity lies inert, unexamined when it counts ….. ” (Peshkin 1988, p.17)

The key point here is that subjectivity cannot be removed. It shapes and mediates our thinking and action in a whole range of ways. Therefore, it needs to be valued understood and utilised . Instead of trying to remove the garment and declare ourselves clean of subjectivity, it is important to acknowledge it, and draw upon it in deep analysis to inform decision making.

(for an alternative critique of post modernism in social work click here)

The practical application of EBP

Research from Scandinavia suggests whilst practitioners support the notion of EBP it is rarely applied in a way that is conducive to improved decision making. Their findings highlighted a number of fundamental flaws, which may be relevant to practice in the UK. Firstly, the research found professional autonomy is not a given , suggesting the greatest barrier to practitioners engaging in EBP is the organisational context.

The research identified five significant organisational issues which impeded practitioners from adopting a more focused EBP approach to inform practice;

  1. No access to databases where they can search for, and evaluate research
  2. Time constraints
  3. ‘Organisational logic’ (predictability) prioritised over a ‘logic of care’ (unpredictability)
  4. A focus on following organisational guidelines which aligns EBP with organisational logic to guide decision making
  5. Financial considerations taking priority over research findings to inform practice

The research concludes whilst social workers were not content with the current conception of  EBP they felt incapable of challenging it. The issues highlighted in this research provide little that is new, previous research seems to support these recent findings and arguably leaves practitioners in an untenable position, from both a philosophical and a ‘professional capability’ perspective.

Creating an alternative approach in my practice

Just as practitioners may find themselves out of kilter with EBP, I too have experienced the oppressive effects of  the polarity that exists in understanding EBP when combined with organisational logic in a Higher Education setting.

As a lecturer I am more used to drawing on the objective research knowledge of ‘expert’ academic others to inform my practice, where objectivity and evidence based practice is privileged as an expression of professionalism. However, the eloquent exploration  by Staller (2007) of the interaction between a social worker and sexually abused child resonates with my experience of the polarity which exists in presenting objectivity as synominous with professionalism as she writes

He speaks about his responsibility to retrieve objective stories from sexually abused children, knowing He holds their heart in His hands‘ (p.766). Going onto to suggest ‘His need to get an “objective” story is because the alternative is subjective or fictitious’ (Staller,2007;p.776).

Staller’s experience of encountering this exchange provided a ‘trigger’ moment. Her experience has become the ‘data’ which she will explore from every angle possible to locate that moment within the social, cultural and political realms. This process then has the potential to extract new learning from her experience, to create and share knowledge which will enhance practice.

Reading Stallers work provided a ‘trigger’ moment for me, where I filtered its meaning using the theoretical lenses of modernism and post modernism,   to try and be aware of, and make sense of, how I decide what ‘counts’ as knowledge and how I create and transform data into knowledge, and then ‘evidence’ to support my professional self.  I also had to locate my thoughts in the wider context of the organisation I work in, and the current  structural frameworks which directly influence current practice within higher education (i.e. the use of metrics to ‘rate’ the quality me and my institution, and so inform prospective students how ‘good’ I am, we are – I will leave this for another blog!)

It has also become apparent how the contested nature of ‘subjectivity’ in EBP serves those in power well. By excluding the ‘subjective’ voice of those in society who are marginalised, their stories, their experiences and their knowledge is discarded, branded as unscientific, not rigorous, not valid …… whose interests does this serve? 

(WARNING – Shameless plug here: From this, and subsequent experiences,  my colleagues Annastasia Maksymluk  , who has used auto-ethnography in curriculum development & Andy Whiteford , who focuses on sustainability, and I have collaborated to create a ‘no smoke and mirrors’ research and writing partnership, from which we developed  an open access on-line peer reviewed journal the Journal of auto-ethnography for health and social care). We encourage submissions to the journal from anyone who wants to be part of producing evidence to inform practice;  students, professionals, service users, patients – all are welcome!

Conclusion

Regardless of whatever EBP might, or might not be, it appears practitioners are currently expected to work within a model of EBP which might be more accurately conceptualised as OBP, Operational Based Practice , where professional decision making is centred in processes designed to meeting organisational demands. This is problematic because

“ …it is argued that whatever group controls the way things are seen in some ways also has the power to control the ways things are. Whoever’s interpretation gets accepted will doubtless control how the idea is enacted.” Fook (2002:37).

From this perspective the production, and application, of ‘evidence’ is the product of deliberate, conscious human design, which is amenable to a whole host of organisational, ethical and political requirements. Evidence is not value-free and we need to ask what values and processes currently underpin the discourse that surrounds and shapes EBP in education, research and practice and whether these align to the professions values and ethics?

From a logic perspective EBP provides a neat linear model of deliberated decision making. However, real world social work is rarely a logical, or a linear activity, dealing as it does with often complex and chaotic human lives. Lives where meaning is constructed by a variety of individuals, and subjected to a plethora of structural and organisational filters that heavily influence the practice of decision makers and the lives of those they work with.

Whilst the notion of EBP has provided the profession, regulators, educators and government, with a seemingly straightforward response to improving decision making in complex cases, the structural realities of practice continue to be ignored, as do the structural inequalities that exist in many of the lives practitioners work with.

Jacob Rees Mogg analysis of problems in ‘care’ provision does not acknowledge his parties role in transforming a profession rooted  in compassion into a commodity traded in the ‘care industry’

Jacob Rees Mogg analysis of ‘care’  does not acknowledge his parties role in transforming a profession rooted  in compassion into a commodity traded in the  ‘care industry’.  Arguably, care is now perceived by government as nothing more than a product, a commodity to be bought, sold and profited from,  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 decent 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.