Tackling wicked problems A public policy perspective Ple.docx
A new vision for adult social care
1. 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:
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3. 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.
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4. 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 of
community care, articulated most clearly in the White Paper Caring
for People (DH, 1989) and related policy documents (see, for example,
DH, 1990; DH/SSI, 1991); the paper goes on to discuss the continued
impact of these issues on contemporary policy, highlighting a number
of 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 and
likely impact of personalization is justified.
Community care
The organizational framework for social care was set by the commu-
nity care reforms of the early 1990s. The antecedents of this policy
have been outlined in a number of places (see, for example, Means
et al., 2003; Lymbery, 2005); the nub of the reforms was contained
in the Caring for People White Paper (DH, 1989). This indicated
the rationale for change, and contained six key objectives for service
delivery (DH, 1989: 5). These objectives have different purposes: put
crudely, 1 and 2 point to critical care principles, 3 and 5 are primarily
administrative and organizational, 4 expresses an ideological prefer-
ence for the independent sector, while 6 refers to the financial basis
of social care.
It has been suggested that the order in which these objectives are
specified is misleading (Lymbery, 2005). In reality, according to Lewis
and Glennerster (1996), the nub of the reforms can be found in the final
objective, the introduction of a new funding structure for social care. A
change in supplementary benefit regulations in 1980 had ensured that
the state financially supported people who entered residential or nurs-
ing home care, irrespective of need (Means et al., 2003); as there was
no way of containing this budget, which increased rapidly until com-
munity care was fully implemented (Lewis and Glennerster, 1996), a
key purpose of policy was to curb expenditure through the simple expe-
dient of transferring a cash-limited sum for community care to local
authorities (Lewis and Glennerster, 1996). At a stroke, the expansion in
numbers of people entering residential and nursing homes was curtailed
because local authorities were not funded at a level that would make
that continued growth a possibility (Lewis and Glennerster, 1996). If
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5. 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
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6. LY M B E R Y — A D U LT S O C I A L C A R E 9
attempt to organize a national response to this (DH, 2002). In turn
this placed greater pressure on care managers’ work (Carey, 2003),
while increasing the likelihood that people would not receive services
that responded effectively to them. As a result, the focus inexorably
shifted on to those with higher levels of need, reducing the potential
for more preventative forms of intervention. Indeed, the relative pau-
city of investment in prevention and rehabilitation has had serious
consequences for policy (Bauld et al., 2000); despite the high value
that service users place on small amounts of preventive assistance (Clark
et al., 1998) tightened eligibility criteria gave little scope for authori-
ties to organize their responses on anything other than a restrictive
basis. As a result the practical definition of need has become dependent
on the availability of resources (Tanner, 2003).
Second, there has been an increasing focus on the overarching goal
of 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 been
gradually developed since the mid 1990s. For example, the concept of
direct payments has been critical: first introduced in the Direct Pay-
ments (Community Care) Act 1996, and extended in scope by the
Health and Social Care Act 2001, they enable people to purchase their
own services. A key purpose of this is to increase service users’ control
over the services they receive. There is now a mandatory requirement
for local authorities to offer direct payments to all adult service users in
England (DH, 2003).
As we shall see, there are many other ways in which these principles
are being promoted within the context of adult social care policy; this
will be the focus of the following section. However, the fact of limited
resources combined with the desire to enhance service users’ choice and
control 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 care
In the early years of the 21st century, the government has sought to
develop policies that are purported to represent a ‘new vision’ for adult
social care. The Green Paper on Adult Social Care (DH, 2005) and the
subsequent White Paper (DH, 2006) are pivotal documents in this
respect. The novelty of the vision promised in the Green Paper (DH,
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7. 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;
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8. LY M B E R Y — A D U LT S O C I A L C A R E 11
Ferguson, 2007), both generally relating to public services (Leadbeater,
2004) and specifically in relation to the development of adult social
care (Leadbeater et al., 2008). This latter document makes bold claims
for 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 that
changing the way in which services are organized and delivered can
bring about major improvements. However, as Ferguson (2007) has
noted, there is no recognition that structural inequalities may need to
be addressed in order to bring about such changes; similarly there is lit-
tle understanding that the resource base for adult social care is simply
inadequate (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 to
greater cost effectiveness: the in Control model has been particularly
actively promoted (Duffy, 2005). Certainly, as Henwood (2008) has
indicated, there is an apparently irresistible force behind the growth of
various forms of SDS: consequently, in her view, there will be change
in this direction irrespective of the reservations of critics. However,
moving to ensure that the potential of policy is realized is undoubtedly
a tricky process.
There are a number of reasons for this, one of which is the very scale
of change. According to Leadbeater et al. (2008) in November 2007
107 local authorities were involved in the in Control system, with 2,300
people receiving individual budgets. This is a miniscule proportion of
the 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 severely
limited. It is estimated that there are only 54,000 recipients of direct
payments 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 payments
has traditionally been low (Leece and Leece, 2006) and where there has
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9. 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
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10. LY M B E R Y — A D U LT S O C I A L C A R E 13
Epochalist descriptions of change
One of the most fundamental problems with the new vision for adult
social care is the nature of the rhetoric that surrounds it. Not content
with arguing that care systems should be improved, the government
has 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 and
present are separate and distinct, belonging to different epochs (du Gay,
2003). In this rhetoric the ‘old’ way of doing things is discredited – as
evidenced by the italicized section in the above quote – and therefore
must be replaced with the ‘new’; this pattern of thinking characterizes
much 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 the
introduction of personalization is typical of the rhetorical function of
the discourse of modernization (Finlayson, 2003), rendering the need
for change as an indisputable fact. The government has also deployed
a ‘discourse of failure’ to characterize previous attempts to engage with
adult social care in order to justify the bold policy initiatives that are
being promoted (Langan, 2000).
One obvious consequence of this is the characterization of those
people who question the orthodoxy of modernization policies – of
which personalization is a clear example – as representative of the forces
of paternalism, conservatism or reaction (Leggett, 2005). Proponents of
personalization are therefore true believers, whose duty it is to compel
others to see things their way – the ‘correct’ way. Needless to say, the
almost Manichean division of the adult social care world into devotees
of personalization ranged against the forces of reactionary conservatism
does not represent the most effective way of securing positive change
for service users.
While epochal arguments can be effective in presenting the case
for change and subsequently mobilizing the support for it (du Gay,
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11. 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
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12. 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 available
research is surely too small in scale to carry the burden of expectation
that policy-makers have placed upon it (Clements, 2008). It is evident
that more needs to be discovered concerning what approaches do or do
not work and in which circumstances they are most effective.
If one takes an historical view, a similar approach was evident in
the introduction of care management under community care (Bauld
et al., 2000). Here, small pilot projects that had been carefully targeted
were extended to encompass the entire system of social care, despite the
partial evidence base. It scarcely needs to be added that care manage-
ment now characterizes the entire social care system, which is deemed
to be in need of complete modernization! It seems, therefore, that the
government may be about to repeat a previous basic error.
Consumer–user tensions
A key problem in the changed structures of adult social care is the unre-
solved tension between needs, rights and resources, and the consequent
conflict between conceiving of service users as primarily citizens (with
rights) or consumers (able to exercise choices) (Clarke et al., 2007).
Much of the pressure to change the pattern of adult social care has
come from the user-led movement, which stems directly from notions
of citizenship (Beresford, 2007). By contrast, much policy is set within
a consumerist frame of reference, on the basis that the articulation of
choice will provide solutions that can transcend past problems (Clarke
et al., 2008). Interestingly, however, these developments have appro-
priated the radical language of user movements, and applied it within
a 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.
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13. 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
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14. LY M B E R Y — A D U LT S O C I A L C A R E 17
is that many older people may not wish to undertake the activities
upon which self-directed support depends – nor indeed be capable of
undertaking them. Certainly, older people in receipt of social care expe-
rience severe disruption to their lives caused by their escalating care
needs – a point confirmed by the IBSEN (individual budgets evalu-
ation network) evaluation (Glendinning et al., 2008) – alongside the
likelihood that the effect of FACS was to confirm that little or nothing
would be available to them at an early stage in their problems.
In addition, as Oldman (2003) has argued, older people may have
more 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 in
later life that encompasses these themes as connected realities of their
existence appears to be ignored. As a result, the complexities of many
older people’s lives are at risk of being oversimplified with the genuine
areas 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 next
few years (Alzheimer’s Society, 2007), there will be larger numbers of
older people who are unable to conform to the simplistic definition of
independence that is advanced. What such people will require is both
recognition of their changing circumstances – particularly their increas-
ing levels of dependence – alongside the opportunity to exercise as much
choice and control as they can. It seems that the simplistic construction
of policy is incapable of responding well to these complexities.
Protection
There is a general lack of fit between policies concerned with promot-
ing independence and choice, and policies that have the protection
of vulnerable adults as their primary focus (Fyson and Kitson, 2007).
While it has been recognized that increased levels of risk are possible
under the new arrangements (CSCI, 2008a) there appears little con-
crete support that would enable people or individuals to manage this
process effectively. Indeed, the CSCI document (2008a) that focuses on
safeguarding is much better at the level of rhetoric than in outlining
specific steps to be taken to minimize the risk encountered by adults.
Certainly, the ‘fetishization’ of conceptions of independence and choice
in the social care world (Fyson and Kitson, 2007) has progressed to such
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15. 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).
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16. 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 bland
consensual discourse of partnership as self-evidently necessary has failed
to take account of the political realities that characterize partnership
work (Newman, 2001). This is compounded by continued squabbles
over the funding of social care, where discussions over the distribution
of health and social care budgets remain the focus of considerable acri-
mony (Brindle, 2007). Consequently, it is difficult for the government
to commit the resources that might make their optimistic vision come
to fruition – particularly at a time of extraordinary pressure on public
finances.
Resources
Consequently, the adequacy of the resource base for this new policy
development remains the critical question. Evidence from the compre-
hensive IBSEN evaluation (Glendinning et al., 2008) suggests that
there has been limited progress towards the incorporation of funding
streams from outside social care: since a key characteristic of individual
budgets was always intended to be their capacity to draw on such funds
(Clements, 2008), this criticism bears on a fundamental aspect of policy
change. At the same time, all local authorities are currently required to
work within the context of the FACS policy guidance (DH, 2002). Four
eligibility bands have been broadcast: within these, local authorities are
to 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 preventive
work (DH, 2005), the way in which the FACS guidance is interpreted
in practice runs directly counter to this possibility. For example, in
73% of local authorities the only needs met are those defined as ‘sub-
stantial’ (Carvel, 2007), an increase on previous years. This shift has led
even government-established bodies to question the impact of policy as
well as its direction (CSCI, 2006). In addition, a few local authorities
provide 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
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17. 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
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18. 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 this
question.
It is also significant that large amounts of public finance will be
needed to support the proposed changes. Over many years, the need for
a proper accounting of the use of public money has characterized most
aspects 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 for
expenditure – self-assessment, for example – acceptable against the audit
standards expected for public finance? It defies belief that this area of
policy development will not be subjected to the same scrutiny as other
areas of public service; however, there is little clarity about the arrange-
ments that might ensure an equivalent level of financial accountability.
Conclusion
The preceding gives an indication of some of the practical issues that
have to be overcome in order for the government to realize its policy
intentions 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 existence
of several issues while underestimating the significance of others. As a
result, it is proceeding on a combination of inflated rhetoric and largely
irrational optimism.
As Clements (2008) has pointed out, to highlight the potential
pitfalls in the way of adult social care policies is not necessarily to chal-
lenge every tenet of the personalization agenda. Although the concept
of 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 to
ensure that any criticism of the practical issues of change is taken as
opposition to its essential principles. In this respect, Finlayson’s com-
ments about modernization generally seem to be clearly applicable to
personalization policies:
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19. 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.
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23. 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
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