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A new vision for adult social care
 

A new vision for adult social care

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What will come of adult social care? This paper by Mark Lymbery is a brilliant overview of the plans for the future.

What will come of adult social care? This paper by Mark Lymbery is a brilliant overview of the plans for the future.

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    A new vision for adult social care A new vision for adult social care Document Transcript

    • Critical Social Policy http://csp.sagepub.com/A new vision for adult social care? Continuities and change in the care of older people Mark Lymbery Critical Social Policy 2010 30: 5 DOI: 10.1177/0261018309350806 The online version of this article can be found at: http://csp.sagepub.com/content/30/1/5 Published by: http://www.sagepublications.com Additional services and information for Critical Social Policy can be found at: Email Alerts: http://csp.sagepub.com/cgi/alerts Subscriptions: http://csp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://csp.sagepub.com/content/30/1/5.refs.html Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    •  MARK LYMBERY University of Nottingham A new vision for adult social care? Continuities and change in the care of older people Abstract The reform of adult social care is a major preoccupation within England. It is presented as the inevitable consequence of the changed expectations of people who use services; in addition, the detail of policy is portrayed as being in accordance with what those people specify they want from social care. However, there appears to be little recognition of the complexities and contradictions that characterize much of the policy. Of these, the inadequacy of the resource base of adult social care is most significant; consequently, rationing of scarce resources will continue to be a priority. The paper also highlights problems in other areas, including the rhetoric that accompanies policy change and the evidence base for that change, the lack of connection between issues of independence and protection, the partial understandings of partnership that appear to characterize it and the inadequate conceptualizations both of the nature of those people who require social care support and of the character of that support. In discuss- ing these issues, the paper emphasizes that there remain continuities in the context of policy, while noting the continual focus on discontinuity within government documents. Key words: personalization, social care policyIntroductionAdult social care in England is undergoing major changes. The labelof ‘personalization’ has been attached to this policy (Leadbeater et al.,2008); it is suggested that the individual should be placed at the heartof service provision, in turn ensuring a maximum level of responsive-ness to what that individual desires. It is quite typical of governmentpolicy rhetoric that this apparently straightforward idea encompasses© The Author(s), 2010. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.navCritical Social Policy, 0261-0183 101; Vol. 30(1): 5 –26 341899 10.1177/0261018309350806http://csp.sagepub.com 5 Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 6 CRITICAL SOCIAL POLICY 30(1) a strong implication that the existing pattern of services has been entirely inadequate. Indeed, the development of personalization has been accompanied by continued assertions about the perceived inflex- ibility and paternalism of existing welfare services (HM Government, 2007). It is suggested that it will require a radical transformation to the pattern of service delivery, and that this will fundamentally alter the way in which society responds to individuals’ needs. The pace of development is rapid: local authorities are required to make measurable improvements by 2011, and £520 million (the social care reform grant) have been allocated to English local authorities to enable them to make these changes (DH, 2008). This paper will suggest that there are several problems with the proposed policy, particularly in relation to the care needs of older peo- ple, and that these barely seem to have been recognized by the gov- ernment. Chief amongst these problems is the resource base of adult social care, which has been identified as grossly inadequate in relation to known demographic change even before considering the impact of an improved focus on outcomes (Wanless, 2006). Indeed, the govern- ment has repeatedly specified that the development of adult social care ‘must be set in the context of the existing resources and be sustainable in the longer term’ (DH, 2008: 7). In addition, there are numerous other issues over which policy appears to skate, rather than engaging fully with their implications. These include the complexity of managing the balance between the enhancement of individuals’ independence against the reality that – for many – dependence, vulnerability and the consequent need for protec- tion are dominant features of their lives. Similarly, many vulnerable people – particularly, perhaps, older people (Glendinning et al., 2008) – may struggle to exercise the control and choice that are central to the policy. This creates a situation of more complexity than is allowed for in official accounts. Critically, perhaps, the very formulation of policy presents a number of problems. As Williams (in Ferguson, 2007: 387) has suggested, it is hard to be critical of a concept that appears to be so ‘warmly persuasive’; it is also typical of adult social care that such terms are frequently used to describe the policies that are introduced – ‘community care’ being a clear example. The apparent attractions of the term should not distract us from developing a critique of the policy that it describes, which can be applied at the level of both generality and detail. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 7 This issue is explored by critically examining the key elements ofcommunity care, articulated most clearly in the White Paper Caringfor People (DH, 1989) and related policy documents (see, for example,DH, 1990; DH/SSI, 1991); the paper goes on to discuss the continuedimpact of these issues on contemporary policy, highlighting a numberof unresolved tensions in the implementation of personalization poli-cies. It concludes by arguing that the continuing nature of these prob-lems ensures that a healthy scepticism concerning the feasibility andlikely impact of personalization is justified.Community careThe organizational framework for social care was set by the commu-nity care reforms of the early 1990s. The antecedents of this policyhave been outlined in a number of places (see, for example, Meanset al., 2003; Lymbery, 2005); the nub of the reforms was containedin the Caring for People White Paper (DH, 1989). This indicatedthe rationale for change, and contained six key objectives for servicedelivery (DH, 1989: 5). These objectives have different purposes: putcrudely, 1 and 2 point to critical care principles, 3 and 5 are primarilyadministrative and organizational, 4 expresses an ideological prefer-ence for the independent sector, while 6 refers to the financial basisof social care. It has been suggested that the order in which these objectives arespecified is misleading (Lymbery, 2005). In reality, according to Lewisand Glennerster (1996), the nub of the reforms can be found in the finalobjective, the introduction of a new funding structure for social care. Achange in supplementary benefit regulations in 1980 had ensured thatthe state financially supported people who entered residential or nurs-ing home care, irrespective of need (Means et al., 2003); as there wasno way of containing this budget, which increased rapidly until com-munity care was fully implemented (Lewis and Glennerster, 1996), akey purpose of policy was to curb expenditure through the simple expe-dient of transferring a cash-limited sum for community care to localauthorities (Lewis and Glennerster, 1996). At a stroke, the expansion innumbers of people entering residential and nursing homes was curtailedbecause local authorities were not funded at a level that would makethat continued growth a possibility (Lewis and Glennerster, 1996). If Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 8 CRITICAL SOCIAL POLICY 30(1) this is taken to be the primary objective, the importance of all of the others recedes into comparative insignificance. Although it would be wrong to claim that there had never previ- ously been a process whereby social care services were rationed (Means et al., 2003), community care policy required a more explicit focus on rationing than had been the case beforehand. As a consequence, authorities had to develop eligibility criteria to govern their decisions about what could be provided following assessments (Lymbery, 1998). Increasing problems with resources inevitably led to a process whereby eligibility criteria were gradually tightened in order to enable authori- ties to manage their finances (Arksey, 2002). This becomes particularly significant when considering some of the other policy priorities of com- munity care. For example, the act of assessment (linked to objective 3) has been critical in community care: owing to the limited resource base the allocation of services has been based on rigorous assessment of need, a task that was viewed as a skilled activity carried out by paid employ- ees of local authorities. These ‘care managers’ were critical to the success of community care: they held the uneasy balance between expanding levels of need and tightly constrained resources – a task that they often found both irksome and problematic (Postle, 2001). In the light of con- temporary issues – discussed in the following section – it is enlighten- ing that care management was introduced on a universal scale, despite the fact that evidence for its effectiveness had been derived from a small number of tightly controlled pilot projects (Bauld et al., 2000; Means et al., 2003). The first two objectives are particularly interesting, as they rep- resent the aspects of policy that derive from a more principled, value- driven perspective. They chimed with people’s general desire to remain at home for longer, and acknowledged the need for informal carers to be recognized and properly supported. For many professionals – as well as politicians and service users – these goals represented an appropriate aspiration for social care, despite the obvious conflict between them and the governing financial priorities of the policy. This has severely constrained the development of services for carers, for example (Arksey, 2002). As the 1990s wore on, two factors became prominent in the devel- opment of policy and affected subsequent decisions. First, as noted above, the mounting pressure on social care budgets was translated into increasingly restrictive eligibility criteria (Parry-Jones and Soulsby, 2001): the Fair Access to Care Services (FACS) policy represented an Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 9attempt to organize a national response to this (DH, 2002). In turnthis placed greater pressure on care managers’ work (Carey, 2003),while increasing the likelihood that people would not receive servicesthat responded effectively to them. As a result, the focus inexorablyshifted on to those with higher levels of need, reducing the potentialfor more preventative forms of intervention. Indeed, the relative pau-city of investment in prevention and rehabilitation has had seriousconsequences for policy (Bauld et al., 2000); despite the high valuethat service users place on small amounts of preventive assistance (Clarket al., 1998) tightened eligibility criteria gave little scope for authori-ties to organize their responses on anything other than a restrictivebasis. As a result the practical definition of need has become dependenton the availability of resources (Tanner, 2003). Second, there has been an increasing focus on the overarching goalof promoting independence and choice in adult social care (DH, 2005);the latter aspiration is common across public services more generally(Clarke et al., 2008). In order to achieve this radical changes have beengradually developed since the mid 1990s. For example, the concept ofdirect payments has been critical: first introduced in the Direct Pay-ments (Community Care) Act 1996, and extended in scope by theHealth and Social Care Act 2001, they enable people to purchase theirown services. A key purpose of this is to increase service users’ controlover the services they receive. There is now a mandatory requirementfor local authorities to offer direct payments to all adult service users inEngland (DH, 2003). As we shall see, there are many other ways in which these principlesare being promoted within the context of adult social care policy; thiswill be the focus of the following section. However, the fact of limitedresources combined with the desire to enhance service users’ choice andcontrol is at the heart of the problems that surround the implementa-tion of the new policies for adult social care.A new vision for adult social careIn the early years of the 21st century, the government has sought todevelop policies that are purported to represent a ‘new vision’ for adultsocial care. The Green Paper on Adult Social Care (DH, 2005) and thesubsequent White Paper (DH, 2006) are pivotal documents in thisrespect. The novelty of the vision promised in the Green Paper (DH, Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 10 CRITICAL SOCIAL POLICY 30(1) 2005) rests largely in its desire to contribute more broadly to the well- being of adults who need social care support. To accomplish this, policy seeks to increase service users’ independence by enhancing their control over the services provided, and favours the accompanying concept of choice as a means to achieve this. In specific terms, the Green Paper dis- cusses widening access to direct payments; most radically, it also floats the possibility of individual budgets being made directly available to service users – a suggestion that has become central to government policy (HM Government, 2007). To ensure that people have the maxi- mum chance to develop a preventative approach to problems within their own lives, policy also seeks to re-balance the nature of services by focusing on earlier intervention, to counter the reliance on services being made available only to people with high levels of need. This focus has been consistently emphasized in numerous succeeding documents (HM Government, 2007; DH, 2008; ODI, 2008). These broad aims were consolidated into four main goals in the subsequent White Paper: „ Providing better prevention services with earlier intervention; „ Giving people more choice and a louder voice; „ Do more to tackle inequalities and improve access to community services; „ Create more support for people with long-term needs. (DH, 2006: 7–8) The White Paper is typical of the ‘modernization’ project in its belief that improved partnership between health and social care could bring enormous rewards (Newman, 2001; Clarke and Glendinning, 2002). Indeed, from the late 1990s onwards, the importance of collabora- tive working as a means to improve the delivery of welfare has been emphasized in numerous official documents (Lymbery, 2006). It also confirmed the Green Paper’s intention to shift more resources into pre- vention; in addition, it presented the idea that more services should be made available outside hospitals in people’s own homes. This implies a transfer of resources from secondary to primary health care; it could also be interpreted as recognizing that some resources should be transferred from health to social care. The complexities of this will be discussed further in the following section. The work of Charles Leadbeater and colleagues has been highly influential in this area; indeed, Leadbeater has been an important writer for New Labour social policy in more general terms (Finlayson, 2003; Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 11Ferguson, 2007), both generally relating to public services (Leadbeater,2004) and specifically in relation to the development of adult socialcare (Leadbeater et al., 2008). This latter document makes bold claimsfor the potential of personalized services both to provide a more satis-factory response to people’s care needs, and to do so at lower cost: What started as a solution to the intense needs of a small group of social services users has the potential to transform public services used by mil- lions of people, with budgets worth tens of billions of pounds. (Lead- beater et al., 2008: 10; my italics)As is typical of New Labour social policy, there is a presumption thatchanging the way in which services are organized and delivered canbring about major improvements. However, as Ferguson (2007) hasnoted, there is no recognition that structural inequalities may need tobe addressed in order to bring about such changes; similarly there is lit-tle understanding that the resource base for adult social care is simplyinadequate (a theme that is amplified later in this paper). Here, Leadbeater et al. refer particularly to the development of Self-Directed Support (SDS), a mechanism to link improved outcomes togreater cost effectiveness: the in Control model has been particularlyactively promoted (Duffy, 2005). Certainly, as Henwood (2008) hasindicated, there is an apparently irresistible force behind the growth ofvarious forms of SDS: consequently, in her view, there will be changein this direction irrespective of the reservations of critics. However,moving to ensure that the potential of policy is realized is undoubtedlya tricky process. There are a number of reasons for this, one of which is the very scaleof change. According to Leadbeater et al. (2008) in November 2007107 local authorities were involved in the in Control system, with 2,300people receiving individual budgets. This is a miniscule proportion ofthe total numbers of service users; according to their own calculations,approximately 1.7 million people are in receipt of social care services,over a million of whom are over the age of 65 (Leadbeater et al., 2008:22). Similarly, the take-up of direct payments has also been severelylimited. It is estimated that there are only 54,000 recipients of directpayments out of an eligible potential population of around a million(DH, 2008) – which equates to 5.4%. When one considers the particu-lar circumstances of older people, where the take-up of direct paymentshas traditionally been low (Leece and Leece, 2006) and where there has Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 12 CRITICAL SOCIAL POLICY 30(1) been a relatively undeveloped tradition of activism – a characteristic strongly associated with moves in the direction of enhanced choice and control (DH, 2007) – the problem is magnified. The implications of this will be explored further in the following section. This is why the notion of potential was highlighted in the above quote: there is a substantial distance between the aspirations of policy, and its ability to guarantee improvements across the board. Therefore, the extent to which the objectives of policy will be fully achievable is unknown. Since no documents specify precisely how these signifi- cant changes will be brought about there is at least room for scepti- cism about this (Glasby, 2005). Undeniably, since some of the policy goals – notably improved partnership – have been aspirations for at least the past 40 years, it is at the very least a ‘challenge’ for the govern- ment to accomplish changes that have defeated its predecessors. That this will be a complex and potentially problematic process is clear: the following section identifies some of the ways in which these problems may become manifest. Ongoing problems in service development and delivery There are a number of issues that potentially obstruct the effective development of the new vision for adult social care, with particular reference to the concerns of older people. While some of them – issues around partnership and resources, for example – have been recognized as problematic by government, I argue that there has been little apprecia- tion of their depth and complexity. By contrast, other questions – the lack of compelling evidence that the proposals can achieve the change required, and the tensions between the narratives of consumerism and citizenship that underpin the changes – seem scarcely to have been acknowledged at all. The range of issues to be addressed is summarized below: „ Epochalist descriptions of change „ Evidence for change „ Consumer–user tensions „ Support needs „ Protection „ Partnership „ Resources Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 13Epochalist descriptions of changeOne of the most fundamental problems with the new vision for adultsocial care is the nature of the rhetoric that surrounds it. Not contentwith arguing that care systems should be improved, the governmenthas consistently sought to diminish the value of what has gone before.The following passage from the Putting People First concordat exempli-fies this tendency: The time has now come to build on best practice and replace paternalis- tic, reactive care of variable quality with a mainstream system focussed on prevention, early intervention, enablement and high quality personally tailored services. (HM Government, 2007: 2; my italics)Instead of focusing on a sense of continuity between past and present,what is emphasized here is discontinuity: a position where the past andpresent are separate and distinct, belonging to different epochs (du Gay,2003). In this rhetoric the ‘old’ way of doing things is discredited – asevidenced by the italicized section in the above quote – and thereforemust be replaced with the ‘new’; this pattern of thinking characterizesmuch of the government’s rhetoric around ‘modernization’ (du Gay,2003) and can readily be applied to adult social care (Cutler et al.,2007). Indeed, the epochal rhetoric deployed to smooth the way for theintroduction of personalization is typical of the rhetorical function ofthe discourse of modernization (Finlayson, 2003), rendering the needfor change as an indisputable fact. The government has also deployeda ‘discourse of failure’ to characterize previous attempts to engage withadult social care in order to justify the bold policy initiatives that arebeing promoted (Langan, 2000). One obvious consequence of this is the characterization of thosepeople who question the orthodoxy of modernization policies – ofwhich personalization is a clear example – as representative of the forcesof paternalism, conservatism or reaction (Leggett, 2005). Proponents ofpersonalization are therefore true believers, whose duty it is to compelothers to see things their way – the ‘correct’ way. Needless to say, thealmost Manichean division of the adult social care world into devoteesof personalization ranged against the forces of reactionary conservatismdoes not represent the most effective way of securing positive changefor service users. While epochal arguments can be effective in presenting the casefor change and subsequently mobilizing the support for it (du Gay, Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 14 CRITICAL SOCIAL POLICY 30(1) 2003) – and some of the material around adult social care can be seen in this light – they also close off debate: the end product is presented as the only possible solution to the problem. As a result the change is presented as inevitable, not as the outcome of political calculation or negotiation (Cutler et al., 2007); in addition, since only a complete reinvention will suffice the value of more flexible, incremental change processes is denied. This potentially creates a problem in relation to the morale of workers, who are expected to assimilate the fact that all they have done in the past has been wrong. This perspective particularly applies to social workers in this context; the scant references to what they might contribute to policy are usually prefaced by criticism to the effect that they have allowed themselves to become rationers and gatekeep- ers of services, in the words of the Green Paper (DH, 2005); this repre- sents a perversion of reality, and oversimplifies a core problem in adult social care policy (Clements, 2008). In reality, this rationing work has been a requirement of policy, and social workers have found themselves unwillingly drawn into such forms of practice (Postle, 2002). Similarly, arguing for wholesale change to policy denies the possibility that alter- native solutions may work in particular sets of circumstance. Again, the needs of older people should be considered in this context. Are they really best served by the precipitate charge towards personalization? Evidence for change The epochalist tendency creates a particular problem around the nature of evidence for change. The fact that policy is proceeding without robust evidence that would fully support it (Henwood, 2008) repre- sents a fundamental problem. Indeed, if one examines the evidence in detail, it is hard to justify the scope of the changes (Cutler et al., 2007); for example, although the introduction of individual budgets is seen as broadly positive, experience has highlighted concerns that are particu- larly problematic for older people (Glendinning et al., 2008). Clearly, there remain substantial gaps in the overall evidential framework underpinning the proposed changes. Two examples serve to illustrate this: „ Duffy (2005) has generated evidence for the success of SDS – in relation to both outcomes and costs – but only in relation to a small group of service users. In advocating for the potential value of personalized care, Leadbeater et al. (2008) draw on this sort of small-scale work and extrapo- late enormous gains from it. Leadbeater et al. (2008) also approvingly cite Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 15 research by Hatton which involved 196 people across 17 local authorities, another remarkably small sample from which to extrapolate such a major policy change. The ready assumption that it can be automatically trans- lated into success across the entire system permeates official thinking.„ Similarly, the evidence from the evaluation of individual budgets is also based on a relatively small sample. In addition, and this is critical, this evidence does not all flow in an equally positive direction (Glendinning et al., 2008); indeed, there are particular problems in relation to the wide- spread adoption of the principles of individual budgets for older people, as Brindle (2008) has noted.In relation to the overall size and scope of social care the availableresearch is surely too small in scale to carry the burden of expectationthat policy-makers have placed upon it (Clements, 2008). It is evidentthat more needs to be discovered concerning what approaches do or donot work and in which circumstances they are most effective. If one takes an historical view, a similar approach was evident inthe introduction of care management under community care (Bauldet al., 2000). Here, small pilot projects that had been carefully targetedwere extended to encompass the entire system of social care, despite thepartial evidence base. It scarcely needs to be added that care manage-ment now characterizes the entire social care system, which is deemedto be in need of complete modernization! It seems, therefore, that thegovernment may be about to repeat a previous basic error.Consumer–user tensionsA key problem in the changed structures of adult social care is the unre-solved tension between needs, rights and resources, and the consequentconflict between conceiving of service users as primarily citizens (withrights) or consumers (able to exercise choices) (Clarke et al., 2007).Much of the pressure to change the pattern of adult social care hascome from the user-led movement, which stems directly from notionsof citizenship (Beresford, 2007). By contrast, much policy is set withina consumerist frame of reference, on the basis that the articulation ofchoice will provide solutions that can transcend past problems (Clarkeet al., 2008). Interestingly, however, these developments have appro-priated the radical language of user movements, and applied it withina consumerist vision (Ferguson, 2007). As Clarke et al. (2007) indicate,whether or not one perceives of people as citizens or consumers materi-ally affects the ways in which they should be approached. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 16 CRITICAL SOCIAL POLICY 30(1) When seeking to apply the principles of consumerism to social care several core problems emerge. For example, as Clarke et al. note (2008: 249) mechanisms of choice can often replicate rather than amend inequality because more attention is paid simply to ‘the capacity to make choices rather than the capacity to realise choices’ (italics in original). In addition, too little attention is paid to issues of power; as Clarke et al. (2008) have it, although much terminology around the redistribution of power is appropriated from politicized sources such as the disability movement, as re-presented in social care that political dimension is notably absent (see also Ferguson, 2007). Again, this is typical of the absence of broader political considerations from much social policy that falls under the banner of modernization (Finlayson, 2003). This is par- ticularly evident when exploring the adequacy of resources (see below). In reality, where resources are limited the freely exercised choice of one individual may serve to limit the choices made by another (Clements, 2008). The key political point would focus on the adequacy or other- wise of the resource base; although this has been highlighted (CSCI, 2008b) it is not addressed in personalization policies. Rather, it is as if the adoption of such policies will magically resolve the pressing finan- cial problems. There are also tensions in the balance between needs and rights (Mandelstam, 2005) that policy around personalization simply does not explore. These include potential conflicts of interest between users and carers (Glendinning, 2008); in addition, there are unstated assumptions about the nature of service users. For the strategy of personalization to work it is presumed that they will be able to act as both reasonable and responsible consumers (Clarke et al., 2007). Although this may be impossible for many people as a consequence of the effects of their impairments, policy is predicated on precisely such an assumption. Support needs Indeed, much of the rhetoric of personalization is underpinned by a supposition of the characteristics of service users – as not only willing and but also able to maximize control over their lives. This optimistic perspective may be balanced by other, more critical, standpoints. For example, the binary opposition between ‘independence’ and ‘depen- dence’ upon which much policy is based is deeply problematic, par- ticularly in casting ‘dependence’ as such a pejorative concept (Ferguson, 2007). There are two ways in which this may become an issue: the first Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 17is that many older people may not wish to undertake the activitiesupon which self-directed support depends – nor indeed be capable ofundertaking them. Certainly, older people in receipt of social care expe-rience severe disruption to their lives caused by their escalating careneeds – a point confirmed by the IBSEN (individual budgets evalu-ation network) evaluation (Glendinning et al., 2008) – alongside thelikelihood that the effect of FACS was to confirm that little or nothingwould be available to them at an early stage in their problems. In addition, as Oldman (2003) has argued, older people may havemore sophisticated desires for their futures, recognizing and negotiat-ing between themes of independence, dependence and interdependence.However, the possibility that older people may embrace an identity inlater life that encompasses these themes as connected realities of theirexistence appears to be ignored. As a result, the complexities of manyolder people’s lives are at risk of being oversimplified with the genuineareas of dependence that older people may experience likely to be per-ceived as a consequence of their inadequacies rather than their frailties(Lloyd, 2000). Given that the numbers of people with, for example,Alzheimer’s disease, are predicted to increase substantially in the nextfew years (Alzheimer’s Society, 2007), there will be larger numbers ofolder people who are unable to conform to the simplistic definition ofindependence that is advanced. What such people will require is bothrecognition of their changing circumstances – particularly their increas-ing levels of dependence – alongside the opportunity to exercise as muchchoice and control as they can. It seems that the simplistic constructionof policy is incapable of responding well to these complexities.ProtectionThere is a general lack of fit between policies concerned with promot-ing independence and choice, and policies that have the protectionof vulnerable adults as their primary focus (Fyson and Kitson, 2007).While it has been recognized that increased levels of risk are possibleunder the new arrangements (CSCI, 2008a) there appears little con-crete support that would enable people or individuals to manage thisprocess effectively. Indeed, the CSCI document (2008a) that focuses onsafeguarding is much better at the level of rhetoric than in outliningspecific steps to be taken to minimize the risk encountered by adults.Certainly, the ‘fetishization’ of conceptions of independence and choicein the social care world (Fyson and Kitson, 2007) has progressed to such Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 18 CRITICAL SOCIAL POLICY 30(1) an extent that the mere existence of improved levels of independence and choice appears to be taken as sufficient to protect people from abuse (an impression that is substantially confirmed by the diagram on p. 30 of CSCI, 2008a). For older people, there is a particular risk of financial exploitation – and policy may not be effective in ensuring that this does not occur (Manthorp, 2008). The extent of older people’s vulnerability at the point where they need additional support to manage their lives should not be underesti- mated. Authorities will therefore need to act systematically to identify where people are at risk and take steps to ensure that they are protected from the worst possible consequences of that risk. An acknowledge- ment of this should not be equated with the exercise of a paternalistic and old-fashioned conception of services, as epochalist commentaries would seem to suggest: rather it is a practical response to the reality of people’s lives. Partnership The concept of ‘partnership’ has been advanced as typical of the ‘new’ Labour approach to health and social care (Clarke and Glendinning, 2002). Certainly, it has been a significant theme of much official policy (see, for example, DH, 1998, 2000). While much of this writing focuses on the benefits of improved collaboration, there appears to be little recognition of the reasons why collaboration has not advanced further than it has, despite being a policy priority for several decades (Lymbery, 2006). The tendency of official literature to focus on professional rival- ries as the cause of poor collaborative practice has diverted attention from the essentially structural basis of such problems, as Bridgen and Lewis (1999) have suggested. They indicate that the boundary prob- lems between health and social care resulted directly from the political and organizational settlements that saw health care the responsibility of the National Health Service and social care the responsibility of local government in the immediate post-war years. As they see the problem, a combination of the difficulty in differentiating between health care and social care and the continued, long-standing inadequacy of budgets has led to health and social care agencies seeking to define older people as the primary responsibility of the other – an unequal battle which has, in their view, been comprehensively won by health (Bridgen and Lewis, 1999). Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 19 Any attempt to construct a model of partnership that fails to rec-ognize such uncomfortable political realities is doomed to failure.However, this is precisely what appears to have happened: the blandconsensual discourse of partnership as self-evidently necessary has failedto take account of the political realities that characterize partnershipwork (Newman, 2001). This is compounded by continued squabblesover the funding of social care, where discussions over the distributionof health and social care budgets remain the focus of considerable acri-mony (Brindle, 2007). Consequently, it is difficult for the governmentto commit the resources that might make their optimistic vision cometo fruition – particularly at a time of extraordinary pressure on publicfinances.ResourcesConsequently, the adequacy of the resource base for this new policydevelopment remains the critical question. Evidence from the compre-hensive IBSEN evaluation (Glendinning et al., 2008) suggests thatthere has been limited progress towards the incorporation of fundingstreams from outside social care: since a key characteristic of individualbudgets was always intended to be their capacity to draw on such funds(Clements, 2008), this criticism bears on a fundamental aspect of policychange. At the same time, all local authorities are currently required towork within the context of the FACS policy guidance (DH, 2002). Foureligibility bands have been broadcast: within these, local authorities areto ensure that they respond to needs defined as ‘critical’ before ‘substan-tial’, ‘substantial’ before ‘moderate’, and ‘moderate’ before ‘low’. While the FACS framework has been the subject of detailed criti-cism (CSCI, 2008b) it remains a requirement for local authorities.Although the Green Paper argued that this pattern of eligibility cri-teria allowed for an interpretation that could support more preventivework (DH, 2005), the way in which the FACS guidance is interpretedin practice runs directly counter to this possibility. For example, in73% of local authorities the only needs met are those defined as ‘sub-stantial’ (Carvel, 2007), an increase on previous years. This shift has ledeven government-established bodies to question the impact of policy aswell as its direction (CSCI, 2006). In addition, a few local authoritiesprovide services only to those people whose needs are defined as ‘criti-cal’ (Carvel, 2007). Obviously, if a need can only be met at the point Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 20 CRITICAL SOCIAL POLICY 30(1) it becomes ‘substantial’ or ‘critical’ the scope for early intervention is severely constrained. Of course, the reason why local authorities have set such restrictive eligibility criteria is directly related to the inad- equacy of the social care budget in relation to the overall level of need. This makes the slow development of alternative sources of income on which service users can draw a particular problem. The Green Paper (DH, 2005) did recognize that the transition to a preventative agenda would be potentially complex, particularly since any change to the system would need to be met from within exist- ing resources. It specifically invited respondents to consider how the apparent conflict between the intentions of the Green Paper could be reconciled with the FACS guidance. However, there is no reaction to this key question in the subsequent White Paper (DH, 2006); indeed, this remains an unexamined issue across the implementation of many innovative service developments (Henwood and Hudson, 2008). Even where problems with the FACS framework have been addressed directly the conclusion is that the inadequacy of the overall level of funding for adult social care is the single most important issue (CSCI, 2008b). In the absence of a substantial increase in such funding, the issue of ration- ing will remain a requirement for local authorities. Of course, budgetary management has been an important concern from the earliest days of community care, as we have seen. However, there are clear inconsistencies in how the government is responding to the changed circumstances that characterize its new vision for adult social care. For example, at one point in the government’s case for change for care support it explicitly highlights the notion that state funding should be ‘targeted at those most in need’ (HM Government, 2008: 9) – in effect, a continuance of existing policies around eligi- bility criteria. However, elsewhere in the same document it is stated that: ‘A new care system should help people to be independent for as long as possible by focusing on prevention and early intervention’ (HM Government, 2008: 34). In practical terms, the first point represents an acknowledgement that resources are limited, and hence that some process of decision-making will be needed to determine who does – and, by definition, does not – secure access to these limited resources. Implicitly, at least, it supports the principles that have governed FACS (DH, 2002). However, the addition of the second point creates a sig- nificant level of confusion: if resources are to be targeted at those most in need, how then are preventive forms of intervention – central to the Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 21‘new vision’ – to be developed and funded? There is no answer to thisquestion. It is also significant that large amounts of public finance will beneeded to support the proposed changes. Over many years, the need fora proper accounting of the use of public money has characterized mostaspects of local government (Kelly, 2003). However, questions of finan-cial accountability are much less well defined in the new arrangements.What are the required trails that will enable auditors to chart expen-diture? Are some of the ideas that have been advanced as the basis forexpenditure – self-assessment, for example – acceptable against the auditstandards expected for public finance? It defies belief that this area ofpolicy development will not be subjected to the same scrutiny as otherareas of public service; however, there is little clarity about the arrange-ments that might ensure an equivalent level of financial accountability.ConclusionThe preceding gives an indication of some of the practical issues thathave to be overcome in order for the government to realize its policyintentions for adult social care. They do not represent tangential per-spectives on policy: on the contrary, they go to the heart of what is pro-posed. Critically, the government appears to have denied the existenceof several issues while underestimating the significance of others. As aresult, it is proceeding on a combination of inflated rhetoric and largelyirrational optimism. As Clements (2008) has pointed out, to highlight the potentialpitfalls in the way of adult social care policies is not necessarily to chal-lenge every tenet of the personalization agenda. Although the conceptof personalization can be criticized at a fundamental level (Ferguson,2007) that has not been the primary purpose of this paper. However,the essentially commodified characterization of the individual as con-strained by the forces of conservatism that is typical of modernization(Leggett, 2005) is also fundamental to personalization (Ferguson, 2007).In addition, the nature of epochalist rhetoric about social care tends toensure that any criticism of the practical issues of change is taken asopposition to its essential principles. In this respect, Finlayson’s com-ments about modernization generally seem to be clearly applicable topersonalization policies: Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 22 CRITICAL SOCIAL POLICY 30(1) It is a kind of social and political theory . . . that is almost theological or cultic in its capacity to encompass everything or anything the movement might choose to do, while rejecting criticism as a kind of nonsensical heresy. (Finlayson, 2003: 82) However, the primary focus of this paper has been to focus on inad- equacies in the government’s understanding of a range of areas. In particular, there seems to be little acceptance of the realities of the lives and circumstances of those older people who require social care support. As a result, I suggest that the development of policy may be more uneven and problematic than is implied in official documents. As much of the preceding material makes clear, the inadequacy of financial resources represents the most serious threat to policy – a point recog- nized widely by researchers (Henwood and Hudson, 2008) as well as government organizations (CSCI, 2008b), even if not addressed by the specific proposals. Indeed, nowhere is it clear how the resources will be made available that would enable the government’s aspirations to be met. Consequently, during a period of financial austerity, one can have little confidence that the needs of older people will be properly resolved in any future financial settlement. References Alzheimer’s Society (2007) Dementia UK. London: Alzheimer’s Society. Arksey, H. (2002) ‘Rationed Care: Assessing the Support Needs of Infor- mal Carers in English Social Services Authorities’, Journal of Social Policy 31(1): 81–101. Bauld, L., Chesterman, J., Davies, B., Judge, K. and Mangalore, R. (2000) Caring for Older People: An Assessment of Community Care in the 1990s. Alder- shot: Ashgate. Beresford, P. (2007) The Changing Roles and Tasks of Social Work from Service Users’ Perspectives: A Literature Informed Discussion Paper. London: Shaping Our Lives National User Network. Bridgen, P. and Lewis, J. (1999) Elderly People and the Boundary between Health and Social Care 1946–1991. London: The Nuffield Trust. Brindle, D. (2007) ‘Radical Plans for Care Have Personal Touch’, The Guard- ian, Society 3 October. Brindle, D. (2008) ‘Personal Budgets May Prove a Burden’, The Guardian, Society 29 October. Carey, M. (2003) ‘Anatomy of a Care Manager’, Work, Employment and Society 17(1): 121–35. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 23Carvel, J. (2007) ‘Councils Turn Backs on Care for Older People’, Guardian Unlimited [http://www.guardian.co.uk/society/2007/nov/22/longterm- care.socialcare], accessed 11 July 2008.Clark, H., Dyer, S. and Horwood, J. (1998) ‘That Bit of Help’: The High Value of Low Level Preventative Services for Older People. Bristol: Policy Press/Com- munity Care.Clarke, J. and Glendinning, C. (2002) ‘Partnership and the Remaking of Welfare Governance’, pp. 33–50 in C. Glendinning, M. Powell and K. Rummery (eds) Partnerships, New Labour and the Governance of Welfare. Bristol: Policy Press.Clarke, J., Newman, J., Smith, N., Vidler, E. and Westmarland, L. (2007) Creating Citizen-Consumers: Changing Publics and Changing Public Services. London: SAGE.Clarke, J., Newman, J. and Westmarland, L. (2008) ‘The Antagonisms of Choice: New Labour and the Reform of Public Services’, Social Policy and Society 7(2): 245–53.Clements, L. (2008) ‘Individual Budgets and Irrational Exuberance’, Commu- nity Care Law Reports 11 (September): 413–30.Commission for Social Care Inspection (CSCI) (2006) The State of Social Care in England 2005–06. London: Commission for Social Care Inspection.Commission for Social Care Inspection (CSCI) (2008a) Safeguarding Adults: A Study of the Effectiveness of Arrangements to Safeguard Adults from Abuse. London: Commission for Social Care Inspection.Commission for Social Care Inspection (CSCI) (2008b) Cutting the Cake Fairly: CSCI Review of Eligibility Criteria for Adult Social Care. London: Commis- sion for Social Care Inspection.Cutler, T., Waine, B. and Brehony, K. (2007) ‘A New Epoch of Individual- ization? Problems with the “Personalization” of Public Sector Services’, Public Administration 85(3): 847–55.Department of Health (DH) (1989) Caring for People: Community Care in the Next Decade and Beyond. Cm. 849. London: HMSO.Department of Health (DH) (1990) Community Care in the Next Decade and Beyond: Policy Guidance. London: HMSO.Department of Health (DH) (1998) Modernising Social Services. Cm. 4149. London: The Stationery Office.Department of Health (DH) (2000) The NHS Plan. London: HMSO.Department of Health (DH) (2002) Fair Access to Care Services: Guidance on Eligibility Criteria for Adult Social Care. Local Authority Circular LAC (2002)13. London: Department of Health.Department of Health (DH) (2003) Community Care, Services for Carers and Children’s Services (Direct Payments) Guidance England 2003. London: Department of Health.Department of Health (DH) (2005) Independence, Well-Being and Choice. London: The Stationery Office. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 24 CRITICAL SOCIAL POLICY 30(1) Department of Health (DH) (2006) Our Health, Our Care, Our Say: A New Direction for Community Services. Cm. 6737. London: HMSO. Department of Health (DH) (2007) Modernising Adult Social Care – What’s Working. London: Department of Health. Department of Health (DH) (2008) Transforming Social Care. Local Authority Circular LAC (DH) (2008) 1. London: Department of Health. Department of Health/Social Services Inspectorate (DH/SSI) (1991) Care Management and Assessment: Practitioners’ Guide. London: HMSO. du Gay, P. (2003) ‘The Tyranny of the Epochal: Change, Epochalism and Organizational Reform’, Organization 10(4): 663–84. Duffy, S. (2005) ‘Individual Budgets: Transforming the Allocation of Resources for Care’, Journal of Integrated Care 13(1): 8–16. Ferguson, I. (2007) ‘Increasing User Choice or Privatizing Risk? The Antino- mies of Personalization’, British Journal of Social Work 37(3): 387–403. Finlayson, A. (2003) Making Sense of New Labour. London: Lawrence and Wishart. Fyson, R. and Kitson, D. (2007) ‘Independence or Protection – Does It Have to be a Choice? Reflections on the Abuse of People with Learning Dis- abilities in Cornwall’, Critical Social Policy 27(3): 426–36. Glasby, J. (2005) ‘The Future of Adult Social Care: Lessons from Previous Reforms’, Research, Policy and Planning 23(2): 61–70. Glendinning, C. (2008) ‘Increasing Choice and Control for Older and Dis- abled People: A Critical Review of New Developments in England’, Social Policy and Administration 42(5): 451–69. Glendinning, C., Challis, D., Fernandez, J.-L., Jacobs, S., Jones, K., Knapp, M., Manthorpe, J., Moran, N., Netten, A., Stevens, M. and Wilberforce, M. (2008) Evaluation of the Individual Budgets Pilot Programme: Final Report. York: Social Policy Research Unit, University of York. Henwood, M. (2008) ‘Here to Stay’, Community Care 20 March, p. 30. Henwood, M. and Hudson, B. (2008) Lost in the System? The Impact of Fair Access to Care. London: Commission for Social Care Inspection. HM Government (2007) Putting People First. London: HM Government. HM Government (2008) The Case for Change: Why England Needs a New Care and Support System. London: Department of Health. Kelly, J. (2003) ‘The Audit Commission: Guiding, Steering and Regulating Local Government’, Public Administration 81(3): 459–76. Langan, M. (2000) ‘Social Services: Managing the Third Way’, pp. 152–68 in J. Clarke, S. Gewirtz and E. McLaughlin (eds) New Managerialism, New Welfare? London: SAGE, Open University. Leadbeater, C. (2004) Personalisation through Participation: A New Script for Public Services. London: Demos. Leadbeater, C., Bartlett, J. and Gallagher, N. (2008) Making it Personal. London: Demos. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • LY M B E R Y — A D U LT S O C I A L C A R E 25Leece, D. and Leece, J. (2006) ‘Direct Payments: Creating a Two-Tiered System in Social Care?’, British Journal of Social Work 36(8): 1379–93.Leggett, W. (2005) After New Labour: Social Theory and Centre-Left Politics. Basingstoke: Palgrave Macmillan.Lewis, J. and Glennerster, H. (1996) Implementing the New Community Care. Buckingham: Open University Press.Lloyd, L. (2000) ‘Dying in Old Age: Promoting Well-Being at the End of Life’, Mortality 5(2): 176–88.Lymbery, M. (1998) ‘Care Management and Professional Autonomy: The Impact of Community Care Legislation on Social Work with Older Peo- ple’, British Journal of Social Work 28(6): 863–78.Lymbery, M. (2005) Social Work with Older People: Context, Policy and Practice. London: SAGE.Lymbery, M. (2006) ‘United We Stand? Partnership Working in Health and Social Care and the Role of Social Work in Services for Older People’, British Journal of Social Work 36(7): 1119–34.Mandelstam, M. (2005) Community Care Practice and the Law, 3rd edn. London: Jessica Kingsley.Manthorp, C. (2008) ‘Older People Could Face the Best or the Worst of Times’, The Guardian, Society 10 December.Means, R., Richards, S. and Smith, R. (2003) Community Care: Policy and Prac- tice, 3rd edn. Basingstoke: Palgrave Macmillan.Newman, J. (2001) Modernising Governance: New Labour, Policy and Society. London: SAGE.Office for Disability Issues (ODI) (2008) Independent Living: A Cross-Govern- ment Strategy about Independent Living for Disabled People. London: Office for Disability Issues.Oldman, C. (2003) ‘Deceiving, Theorizing and Self-justification: A Critique of Independent Living’, Critical Social Policy 23(1): 44–62.Parry-Jones, B. and Soulsby, J. (2001) ‘Needs-led Assessment: The Challenges and the Reality’, Health and Social Care in the Community 9(6): 414–28.Postle, K. (2001) ‘“The Social Work Side is Disappearing. I Guess it Started with Us Being Called Care Managers”’, Practice 13(1): 13–26.Postle, K. (2002) ‘Working “Between the Idea and the Reality”: Ambigui- ties and Tensions in Care Managers’ Work’, British Journal of Social Work 32(3): 335–51.Tanner, D. (2003) ‘Older People and Access to Care’, British Journal of Social Work 33(4): 499–515.Wanless, D. (2006) Securing Good Care for Older People: Taking a Long-Term View. London: King’s Fund. Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010
    • 26 CRITICAL SOCIAL POLICY 30(1)  Mark Lymbery is associate professor of social work at the University of Nottingham. He has a long-standing interest in the development of adult social care policy, and has published widely in this area. In recent times, he has jointly authored Social Work: An Introduction to Contemporary Practice (Pear- son, 2008), jointly edited Social Work: A Companion to Learning (Sage, 2007) and solely authored Social Work with Older People (Sage, 2005). Address: School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham NG7 2RD, UK. email: mark.lymbery@nottingham.ac.uk  Downloaded from csp.sagepub.com at SWETS WISE ONLINE CONTENT on November 8, 2010