Economic and demographic challenges for social care.

Journal of Health Organization and Management Economic and demographic challenges for social care : A critical perspective on the management and delivery of care Will Thomas Sue Hollinrake

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Economic and demographic challenges for social care A critical perspective on the management and delivery of care Will Thomas Business, Leadership and Enterprise, Suffolk Business School, University Campus Suffolk, Ipswich, UK, and

Economic and demographic challenges 653 Received 11 October 2013 Revised 19 May 2014 Accepted 24 June 2014


Sue Hollinrake School of Applied Social Sciences, University Campus Suffolk, Ipswich, UK Abstract Purpose – The purpose of this paper is to analyse the impact of reforms designed to address economic and demographic challenges in England with reference to the authors’ own empirical work providing a critique of their impact and suggesting a way to improve the quality of social care for older people. Design/methodology/approach – The research was a qualitative study conducted in a participatory manner in which older people were positioned as co-creators of the research study. This involved setting the scope of the study and identifying and refining the themes used in the analysis of an inquiry board and interviews. Findings – The research findings highlight the threat of recent moves that emphasise “independence” and “self-management” particularly as they risk marginalising some groups of older people and reducing the quality of care. An alternative approach drawn from the ethics of care is suggested. Research limitations/implications – The research study focused on a narrow selection of older people and future work will wish to explore concepts of “care” and “independence” in additional contexts and of reforms in other geographies. Practical implications – The researchers argue that the current reform agenda threatens the quality of care services and suggest improvements to the way in which services might be organised and presented. Social implications – It is intended that the research will contribute to social policy debates and particularly those that focus on social care. The study also looks to contribute to current work in the fields of critical gerontology, feminist ethics and the management of public services more generally. Originality/value – The paper presents a novel and critical viewpoint of current social care policy in England and will therefore be of interest to policy-makers and to professionals. Keywords Management, Managerialism, Elderly care, Social services Paper type Research paper

Introduction This paper provides a critique of attempts to address significant economic and demographic challenges to the provision of adult social care in England. Reforms that have sought to introduce a managerialist perspective on social care management and The research was funded by a Local Authority with statutory responsibility for the provision of adult social care. The funders were actively involved in the research as described in the paper. The previous version of this paper was presented in the 8th International Critical Management Studies (CMS) Conference, 10-12 July 2013, Manchester, UK. The authors thank the participants of the conference stream Critical Views on Health Care Management for their feedback.

Journal of Health Organization and Management Vol. 28 No. 5, 2014 pp. 653-673 r Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-10-2013-0223

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to place greater responsibility for identifying and organising services in the hand of older people ( personalistation) are evaluated. In doing so, the authors draw upon their own empirical research to highlight the threats that responses to these challenges create for the delivery of high-quality and effective care services. A counter-response, grounded in critical gerontology and drawing upon the ethic of care, suggests how a more effective care service might be organised and delivered. In providing a critique of recent reforms in the light of empirical research and engagement with previous studies, this paper represents a topical and novel analysis of the social care reform agenda in England that presents key learning of value to those working in other contexts. In many economies the global economic crisis has hit resulted in significant pressures on public sector funding of social services and of benefits. In attempting to cut budget deficits, many governments have sought to reduce the cost of social care, resulting in a wide variety of responses and reforms. In this paper, the authors draw on the English context but many of the conclusions will apply to other settings. The economic crisis of 2008 has added to the existing financial pressures on the delivery of adult social care in England (Rogowski, 2010) resulting in reduced budgets for the delivery of statutory care services. In combination with an increase in both demand and in the complexity of needs faced by service users (Gilbert and Powell, 2012; Harvey, 2007) this has presented a significant and important challenge for those planning and delivering adult social care. As a result, the delivery of care services has undergone significant recent change (Lymbery, 2010). In the three years since the beginning of the current UK Coalition Government’s austerity programme, initiated in 2010 to reduce public spending and the budget deficit, there have been major challenges posed by government to the health and social care systems. Approximately £2.68 billion savings have been made by adult social care – 20 per cent of net spending (Association of Directors of Adult Social Services (ADASS), 2013). In 2013, the Association of Directors of Adult Social Services produced a survey of English local authority social care services: the Budget Survey 2013. The results show that despite gains made from the transfer of some resources from the NHS to local authority-funded care social services teams were still faced with making savings amounting to a further £800 million in the 12 months to April 2014. As these cuts continue, the scope for making efficiency savings is reduced and there is an increased likelihood of direct cuts being made to services. Of the 145 authorities that responded to the survey (almost all of a total of 152 top-tier authorities), half thought that fewer people would be receiving support, and those that were would be getting smaller personal budgets (ADASS, 2013). This report stated that 13 percent of planned savings would result in the direct withdrawal of services. An earlier report from the Kings Fund (2013) was similarly pessimistic about local authorities’ abilities to weather these continuing pressures without directly cutting services or affecting quality. This has implications for users such as an increase in charges for services and co-payment, and potentially an increase in unmet needs as local authorities focus their support on only those in greatest need. Although there was a decline in poverty amongst pensioners in the late 1990s, the Department of Work and Pensions found that at the beginning of the twenty-first century, nearly 25 per cent of pensioners in Britain were in poverty (Department of Work and Pensions, 2005). In 2011 Age UK reported that one in six pensioners (1.8 million people) in the UK live in poverty (defined as 60 per cent of median income after housing costs) and that pensioners are also the largest group of people on


the brink of poverty, with 1.2 million on the edge (Age Concern, 2011). With uncertainty surrounding the viability of pensions and retirement plans for many people, there is a likelihood that many older people in future will be financially insecure and less able to meet their own care needs, forcing them to rely on state provision of social care. Older people comprise the largest service user group within social care, not because of their age per se, but because of associated conditions due to ill health, physical impairment, addiction or mental health difficulties. Demographic changes building over the second half of the last century have created a situation whereby it is predicted that by 2021 there will be ten million people over the age of 65 years (Phillipson, 2008). Only a proportion of these will require social care services, but at the same time it is predicted that the number of those with more complex needs will increase ( Johns, 2011). As a result, social care services for older people are under significant pressure to reform to make them more efficient and to reduce the cost to the public sector. In this paper, the authors present a critique of two aspects of policies intended to address the challenges outlined above. In the first case, there have been a number of changes to the way that such services are organised and delivered intended to deliver efficiency in the delivery of adult social care services. These have included a managerialist response whereby targets and efficiency are used to steer reforms and ambitions to make greater use of voluntary or community-based provision. Second, the ambition to see a greater number of older people take responsibility for the management and organisation of their own care has emerged through the allocation of personalised budgets. The authors analyse how these changes to the way in which adult social care services are organised and delivered may affect the quality of care that is offered; whether the response to calls for austerity is compatible with high-quality care services. The response to economic and demographic challenges is discussed in the second section of this paper: “Theoretical Framework”. To support the unpicking of the concept of “quality” in social care services the authors report findings from a small-scale qualitative study that sought to evaluate support provided to older people living at home within an English rural county. This study was undertaken in order to establish first how current support was experienced by those accessing it and second whether this experience identified gaps in provision. This research project is outlined in the third section of the paper: “Research Approach”. The authors’ analysis of data from this study serves to highlight the importance of caring relationships, both formally between providers and recipients of care and informally between recipients of care and friends, family and others who support them. These findings also allow the authors to present an analysis of how reforms to the delivery of adult social care services threaten the quality of relationships which were shown by the research to contribute to the effectiveness of care provision. In doing so, the authors’ research prompts a critique of the adult social care reforms and changes to public services generally, brought about under the New Public Management agenda (Hood, 1991) that took hold in the UK under the Conservative administrations from 1989 and have continued since. This analysis is presented in the fourth section of the paper: “Findings and Analysis”. The authors draw on critical gerontology and feminist theory, using an ethical framework based on the ethics of care to suggest how adult social care services might be managed and delivered in a more effective manner. The suggested framework places a central importance on the quality of caring relationships and enables the authors to offer insight into how such relationships might be nurtured within a social

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care setting. The framework is presented and discussed in the final section of this paper: “Discussion”. This paper contributes to discussions on how to deliver effective and efficient adult social care services within an economic context that restricts spending. It provides a critique of the current reform agenda in England that is driven by responses to economic and demographic challenges. The authors conclude by presenting an argument for the prioritisation of caring relationships as a way to deliver such high-quality adult social care. Theoretical framework Much of the Coalition Government’s enthusiasm for public-sector reform in the UK has focused on its importance for the renewal of the economy. Reforms largely centre on a need to reduce costs and hence the budget deficit. In many countries, including the UK, this has resulted in (central) government restructuring or recasting the areas for which it takes responsibility (England, 2010). Health and social care has been one of the most heavily affected sectors. Reforms to the provision of social care have created a mixed economy of provision which has brought autonomy and choice to those with financial resources of their own. However, cost constraints within social care for those relying on the state for funding have undermined genuine choice (Rogowski, 2010). For the most part, reforms in the UK have taken a traditional neoliberal form with an emphasis placed on opening up the provision of care services to the market. Competition is expected to deliver improved efficiency (Grimshaw and Rubery, 2012) and therefore to reduce the overall costs of delivering care services. The concept of the self-managing, choice-exercising, citizen-consumer that neo-liberal politicians, economists and policy makers promote through social institutions, legitimises a particular consumer lifestyle that emphasise independence and autonomy and in doing so has also individualised risk whereby poorer citizens face greater inequalities in later life (Phillipson, 2006). Those responsible for delivering care services do so with one eye on the metrics by which their performance will be measured: cost savings, customer satisfaction and efficiency have become increasingly important in understanding how well care services are delivered (Tronto, 2013). As they seek to enact this policy objective, care providers must behave in such a way as they reduce the costs of the care that they provide. England (2010) notes as an example that this may result in fewer or shorter visits by home care workers – a situation that has been highlighted in an article in community care (professional magazine) focusing on the poor working conditions of home care workers who are pressurised by employers to carry out care tasks in 15 minute slots to keep costs down (McGregor, 2013). These moves continue to negatively label, and to highlight and artificial “otherness” in, those who are seen to lead dependent lifestyles, relying on either family or formal care services or both. As feminist theorists have pointed out, dependency and a need for care have been construed as problematic and as a deviation from a norm of independence and autonomy (Mahon and Robinson, 2011), and along with other marginalised groups in western societies, older people are seen as burdens within a system that creates binary oppositions – private and public; independent and dependent, without acknowledging the inter-relationships between people that bridge these divides within social relationships (Tronto, 2010). Even without any commitment to personalisation, the effect of the neoliberal focus on cost-reduction and efficiency is “a standoffish behaviour which hinders the development of a responsive relationship”


(ter Meulen, 2008). Roulstone and Morgan (2009) describe the effect as “enforced individualism” where instead of sharing activities and facilities individuals are increasing forced to become self-reliant as a result of direct cuts (to services) or indirect cuts (to other public resource such as libraries). A further concern linked to the current demand to reduce the bill for social care services relates to future capacity and prevention. The focus on short-term savings generated through an emphasis on efficiency delivery also limits the capacity of providers to deliver preventative services designed to offset or reduce needs in the future. Research has shown that a preventative focus on service provision may restrict or reduce the costs of care in the longer term (Fine, 2007). The concept of active citizenship has had a significant influence on developing social policy in relation to older people (Estes et al., 2003), and serves to construct older people who cannot maintain themselves without the help of others as a burden and a potential drain on scarce public resources and reinforce their “otherness”. Active older citizens are volunteers in their local communities and providers of childcare for their families and if they have their own financial resources, then they retain the identity of self- managing consumers if their need for support increases. But if they are neither active nor with financial resources sufficient to provide for themselves, then they become dependent on others physically, emotionally and financially. The former group of active older people form the “third age” which potentially both the last Labour administration and the present Coalition Government have sought to harness in terms of either promoting social inclusion and social capital (Powell, 2000) or the idea of the Big Society (Cabinet Office, 2010; Norman, 2010). Achieving the “Big Society” seems to involve active citizens and active communities in self-help without any real transfer of resources to redistribute from the wealthy to the less wealthy (Corbett and Walker, 2013). Significantly, the rhetorical emphasis on preventative work and community resources under the umbrella philosophy of “The Big Society” and localism has been undermined by the continuing cuts to local authority budgets discussed above. A recently released report (Elkins, 2012) shows how squeezed local authorities are cutting their grants to the voluntary sector where much preventative work in the community occurs. Despite moves made through the Localism Act 2011 to establish new community rights for local people, without the resources to support communities at a local level, little is likely to be achieved in poorer communities that lack strong social capital. Within social care, those who require statutory help (effectively those in substantial or critical need) do so now under the policy of “personalization” (Leadbeater et al., 2008) which crucially changes patterns of service delivery (emphasising choice and independence – a government aim since the mid-1990s, along with self-assessment in some cases) and also changes relationships between service users and social workers. It has been heralded as the individually-tailored solution to previously inflexible and paternalistic welfare provisions (HM Government, 2007), but is also seen as another way of lowering social care costs (Leadbeater et al., 2008). Fotaki (2011) suggests that one of the key reasons for this is the emphasis on economic efficiency described above: the impact of neoliberal reforms to the social care system is to emphasise user-choice and to turn service users into consumers of care services. Stevens et al. (2011) point out that user-choice has been defended as it “increases equity, redresses power balances and develops better services through individual purchasing decisions creating a market pressure on quality”. Whatever the truth, this change creates fundamental challenges for the delivery of high-quality social care.


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A system of personalised care, directed by the individual receiving services, places control in the hands of the person receiving care (Carr, 2008 cited in Duffy, 2010) but only insofar as they are able to make good use of this choice and control. Simply identifying a budget does not guarantee that an individual is going to be able to make good use of this resource. Other factors become important including “the size of that budget, the availability of other services or activities and the existence of support to participate in these activities are also crucial” (Ferguson, 2012). Differences in individual capacities to access the benefits that choice brings (Glendinning, 2008) suggest that individual choice has to be mediated with appropriate support. Professionals remain obliged to assess eligibility for access to care services (to a personal budget for care) (Leece, 2010). As Foster et al. (2006, cited in Leece and Leece, 2011) point out: an assessment based on a professional’s assessment of individual need is an obstacle to creating a system that is truly personalised. But we ought not to see this role of the professional as fundamentally opposed to the notion of greater user involvement in shaping the care that they access. As Tronto (2013) suggests, “determining needs is complicated” and the expertise of someone trained and equipped to mindfully guide the service user is an important aspect of caring (Paulsen, 2011). Currently, assessments leading to judgements about need for care can often be one-off interviews with service users so that relationship-based social work has virtually disappeared from statutory work (Stepney, 2006). This is despite on-going attempts to revive it (Wilson et al., 2011) and the difficulty of achieving properly individually tailored interventions without it (Phillips and Waterson, 2002). Demands for more efficient delivery of social care services have resulted in reducing time with service users, pressure to reduce or remove services for those with moderate or low needs, and despite the personalisation agenda, more standardisation of response (Lymbery, 2010). Ferguson (2007) also points out how personalisation distances the service user from supportive formal relationships by shifting responsibility for organising and managing support onto individuals and thereby privatising risk, and that personalisation also benefits those who are better educated and are thereby able to better manage the processes and negotiate systems. Ferguson also suggests that personalisation may enable cost-cutting, as does Beresford (2007). Against the background of cuts in public services as referred to earlier, a number of key reports have emerged recently which highlight significant failures in a care system that has allowed neglectful and abusive treatment of older people in home care and in hospital (Care Quality Commission, 2011; Equality and Human Rights Commission, 2011; Pearl, 2012; Mid Staffordshire NHS Foundation Trust, 2013). In terms of formal community care services, Slasberg et al. (2012) also suggest how the system of personalisation for the care of old and disabled service users is failing to deliver support because of a shortfall between needs and resources. This suggests a system under stress and a need to review and reappraise how we approach care for those in old age. One of the most striking shifts of recent times, resulting from the implementation of a move towards greater personalisation and the introduction of market-style thinking to social care, has been to see the citizen or recipient of services transform into a “consumer”. The role of consumer brings with it, in this context at least, a degree of implied responsibility: control over a budget represents a shift in the power dynamic between the cared-for and the one(s)-caring (Leece, 2010). As Scourfield (2007 cited in Ferguson, 2012) would have it, the shift towards individualism through the control of personalised budgets brings with it a shifting responsibility from the state to the


individual. Some individuals, such as those with more social capital, will be better placed to manage these responsibilities (Stevens et al., 2011). As service users are increasingly expected to play a consumer-like role in shaping their care, the implication is that the user is willing and able to act as a good neoliberal subject: “the self-governing, autonomous market player” (England, 2010). Tronto (2013) points out that “Market assumptions about the consumer – that she is rational, autonomous, capable of making a choice, and possessed of adequate information to do so – may not characterize the situation of people in care settings”. Many of the people we spoke to recalled difficulties in accessing information, becoming involved in decision-making conversations or, perhaps most crucially, in feeling equipped to play an active role in the process of determining the best care. Prescriptive timescales for managing referrals and resolving crises and problems to satisfy organisational demands within a target-driven culture fuelled by managerialism have undermined the significance of relationships between service users and social workers (Tsui and Cheung, 2004),within which effective, truly person-centred work can be developed to encompass not only the rational but also the emotional aspects of service users’ situations such as lack of confidence, uncertainty about decision making and fears about the future. The current context for social care is therefore dominated by two mutually reinforcing challenges: one economic and driven by the global economic crisis; the other demographic and driven by the effects of an ageing population. The response, at least in England, has been to introduce market-style thinking into the provision of adult social care services. This is demonstrated in the introduction of managerialist reforms within services themselves (a focus on cost saving, efficiency and performance targets) and reforms which seek to put the service user in a position more akin to a consumer of services. In both cases, the authors argue that the reforms threaten the quality of care provided to older people. In the following sections the authors present findings from an empirical study in which they highlight how these reforms impact on and affect older people. In the discussion section an alternative solution is suggested which considers how social care services might be delivered in a more effective way by focusing on the relationships between those providing care and those in receipt of care. Research approach The research study reported in this paper was commissioned by a local authority in England that holds a statutory responsibility to provide social care services for those meeting its threshold criteria. The purpose of the study was to investigate the preventative services provided to adults in the county, with a specific focus on services targeted at older people (aged 60þ ) living in their own home. The commissioners requested that this work should focus on the impact of ill-health and so the project focused on older people with poor health or who had recently been in hospital. This includes services provided by the local authority as well as those provided by charitable organisations and by community groups and volunteers. The design of the research was influenced by participatory and emancipatory methods in which researchers position themselves as “co-creators” of research rather than as “experts”. Whilst the researchers took a more active role than would be anticipated in a truly emancipatory design, older people were actively involved in directing the study and in helping to set a framework which could be used to analyse the data. This was driven by the commissioners of the research who were keen to ensure that the voice of older people was represented as directly as possible. It also


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reflects an epistemological position held by the researchers in which older people are recognised as being expert in their own care, and their own care needs (Leung, 2011). This approach is particularly valuable for researchers seeking to explore issues of care from a perspective of critical gerontology where close attention is paid to the way in which knowledge about ageing and old age is created. Respecting and valuing the voice of older people by involving them in the design of the study is, in the authors’ view, the most effective way of promoting the distinctive voice and experience of these participants. The study was conducted in two parts. In the first part, a group consisting of older people (recruited through the University of the Third Age), representative bodies (including Age UK) and service providers (including the local authority and other providers of contract services) met twice. The group consisted of 15 participants (six older people, four from representative bodies and five from service providers) plus the two researchers. During the first meeting, in line with the researchers’ ambition to recognise the participants as co-creators of the research, there was a focus on setting the scope for the study: identifying the issues that need to be addressed and agreeing the terminology. Between meetings there was sufficient time to allow the researchers to conduct some initial analysis (presented at the second meeting) and to do such factfinding and information gathering as directed by the first meeting of the inquiry board. The analysis of the discussions from both meetings of this group shaped both the schedule for interviews in the second stage of the research, and the framework through which the research would be analysed. In both these ways, the group was therefore key in steering the research and was termed an “inquiry board” rather than a focus group. This terminology was chosen to highlight the distinction from a focus group and to reinforce the position of the board members as leading and shaping the work, with the researchers acting as enablers or co-constructors. The researchers brought a loose structure to the first board based on a review of literature and their own experience. During the discussions, the board members were able to shape conversations to reflect issues that they felt to be important or that reflected their own experiences (in many cases in a very immediate way). The researchers’ role was to facilitate discussions and to support the group dynamic by ensuring that board members were able to contribute as they wished. Inquiry board meetings were recorded and transcribed to allow for more detailed analysis that could be firmly grounded in the data collected. In the second meeting, the board was presented with some initial analysis of discussions from the first board meeting. The researchers had drawn out themes from the discussions, grounding them in the words of board members. Discussions from the first meeting were subjected to a thematic analysis (Braun and Clarke, 2006) in which patterns in the discussions were identified and organised. The transcripts were read closely, broken down into coded extracts which could then be recombined into themes. The ambition was to further develop the emerging themes in the second inquiry board in order to determine an agenda for the second stage of the research and to provide a framework through which interview data could be analysed and presented. In this meeting, plenary sessions of all group members were supplemented with smaller groups which allowed board members to identify and explore issues in more detail. This approach ensured that inquiry board members played an active role in supporting the direction of the analysis (although final analysis was undertaken by the researchers). In the second stage of the research, 22 interviews were conducted with older people determined to be at risk of requiring a move from their own home to a care facility.


Seven people were contacted through services that cater for older people returning home from a hospital visit; nine people were interviewed at rehabilitation units that cater for people who either have less serious conditions or who are between hospital and home; six people were interviewed in small groups (three at a time) at a day-care centre. The majority of interviews were with individuals, with two couples participating. Interviews were semi-structured using a schedule developed following the discussions of the inquiry board. Interviews were not recorded but notes were taken and typed up as soon as possible after the conclusion of the discussion. The decision not to record interviews, but rather to take detailed notes was necessary for practical reasons having taken advice that recording interviews in this context might be considered intrusive by some participants. However, researchers took care to record a number of verbatim quotes and to type up the record of the conversation (using the interview schedule as a guide) as soon as possible following completion of the interview and within 24 hours. Great care has been taken to ensure that the notes made are as reliable as possible; the researchers are experienced in the use of this technique for undertaking research projects of this sort. Data from the project was analysed throughout the duration of the project in order to inform both the direction of the research and its final analysis and presentation following the approach outlined above. In particular, the thematic approach taken to the analysis of the inquiry board information ensured that well-defined themes could be used to provide a framework for the analysis of interview data. Comments and opinions could be compared and contrasted in order to refine the definitions of themes and to highlight nuances in their description. Data analysis was conducted inductively to generate themes from the data, seeking similarities, differences and connections within and between the participants’ accounts of their experiences. In this way the data was fragmented and reduced until patterns emerged that could be interpreted and then organised into key themes (Sarantakos, 2005). NVivo software was used to code extracts and comments from the interview notes using the themes identified from the first stage of the research as a guide. The trustworthiness of the findings is supported by the relatively long (nine month) engagement with the project by researchers; triangulation of results with those of previous studies; checking of findings and analysis with participants; and by keeping detailed notes and an audit trail of the data collection and analysis. Findings and analysis Notes and transcripts (from inquiry board meetings) were subject to continuous analysis throughout the project with input from participants as described above. Three broad themes emerged from the data and are summarised below. These themes focused on: issues relating to knowledge and communication; issues relating to the structure of care and support services; and issues that relate to responsibility for managing care. Accessing knowledge and information about care For most participants, the key issues related to timing and quality of information and to understanding how these issues were communicated to those they affected. One member of the inquiry board summed up these issues well: I found that it was only because I’m the sort of person to find out and to push people that I was able to find anything out. I had to do an awful lot of work myself because people would give me a little bit of information and that you will go along with that and when the need


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arises you’ll go along for something else [y] I found I went on opening more and more doors and thought “why didn’t you tell me at the beginning?” (older person, first inquiry board).

Several other participants reported how being able to rely on relatives who also had previous experience of the care system or of services was beneficial in finding what services was available and how to access it. Even without any previous experience, many participants recalled how important it was to have someone who was able to help with sourcing information about what support is available. Importantly, the issue did not seem to be linked to a lack of information, just how straightforward it was to access the information when it was required:


The people we’re talking about who’ve just come out of hospital [y] it takes an awful lot of time and dedication to work your way through the list of phone calls [y] and to press buttons on the phone (support service member, second inquiry board).

Good-quality decision making is reliant on being able to access suitable information in a timely manner. For most of the older people that participated in our project access to information was a significant problem for which they would be reliant on support from friends and family. Those without these support networks were significantly disadvantaged in this regard and this seriously limits their capacity to direct their own care. Where support networks are not available to support the decision-making process there is a clear need for a high-quality independent brokerage and advice service (Leece and Leece, 2011). Those with weaker (or weakening) social networks were less well-equipped to manage social opportunities – frequently this was associated with transition between third- and fourth-ages. This suggests that the same people would find it difficult to take on the responsibilities of budget-management or of acting as an employer, and belies the assumption underpinning personalisation and other social care reforms that we are all (and only) rational economic actors (Hood, 1991). These research findings support the work of Leece (2010), Scourfield (2007) and Stevens (2011) who similarly find that social networks (or capital) affect the capacity of older people to access information and to make informed decisions about the care available to them. Proper discussion of the options available for older people was also an important issue with a number of participants recalling how they felt left out of decisions that affected them. One participant described being moved from hospital to the rehabilitation unit without having this discussed with her. In another case, a participant was pleasantly surprised to find that she would receive some support at home after returning from hospital. Not all participants were left out of decisions though: another woman, who had suffered a stroke, had been involved in discussions around her discharge and felt happy with this level of involvement. In other cases neither the older person, not their family, seem to be involved with the decisions that are made concerning them: My father was sent in as an emergency on Monday morning [y] we hung around all morning, in the afternoon my daughter and my son came up visit him. We all went home together about ten to four and before I left I said, “do you know what’s happening?” [y] so five o’clock I had a phone call to say” come and get him, he is ready to go home”. I said “hang about I have only left your ward three quarters of an hour ago” (older person, speaking as family member, second inquiry board).

Whilst there was a variation in the ability and interest in seeking out information by the service users themselves, many relied, in varying degrees, on relatives for support and even expected this involvement as a feature of their family culture. Ensuring timely access to high-quality information can enhance these supportive relationships


and ensure that both the older person and their carers (if they have any) can be actively involved in decision making that shapes their care. These findings suggest that a neo-liberal conception of service users as rational choice-agents is flawed in its assumption that those placed in a situation of needing to make choices are able to do so in an informed way.

Economic and demographic challenges

The impact of the structure of the social care system The impact of reforms which have highlight and prioritise short-term costs rather than long-term values was particularly evident in the theme that related to the impact of structure within the social care system. The boundaries between agencies providing care had a very significant impact on the care experience of participants, but serve to limit the work statutory providers are funded to undertake and their obligations to service users. We heard descriptions that indicate the distinctions between providers appear to the service user to be arbitrary and inconsequential:

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You come out of hospital and you get 6 weeks care and then it goes to a different system. When I pushed to find out the difference, it was that the money comes from the hospital for the first 6 weeks and after that it comes from the county. I didn’t need to know that, all I want is a service that flows through (older person, interview 3).

There were several other cases where interviewees felt that the care that they were offered as part of the available package was not suited to their needs. Rigid rules were often applied by providers limiting the perceived quality of the care experienced: [y] we were talking about even the six week care where you get four half hour sessions but you can’t have them as one two hour session and people will do exactly what’s on their little list to do despite the fact that there might be something absolutely crashingly obvious that needs doing more so its getting at, and we keep talking about person centred, person centred, person centred, there is nothing person centred about a tick list if it’s the way we say so we do the laundry (service provider, first inquiry board).

Boundaries within and between agencies also impact on the quality of communication with several participants describing issues specifically focused on the point of discharge (the study recruited participants with a recent experience of hospital care): They say you’re coming out. You sit in a wheelchair then with possibly your belongings and they say you’ve got to wait for your medication, well the pharmacy department obviously think they are superior to the rest of the hospital because they don’t ever liaise [y] they don’t liaise at all so that poor person who has already had enough trauma is sitting in that wheelchair and also waiting (older person, interview 6).

Complexities in the system, and in particular the move towards personalised budgets risk creating additional confusion for many of those trying to access care. In most cases those we spoke to expressed a desire to remain independent of state support where they could; either by managing on their own, through community or charitable organisations or with the help of friends and family. There was, however, an expectation from many that the state would be there to help them by providing care if and when they needed it – some but not all expressed this as an entitlement derived from years of contributions in the form of social security payments. An adequate brokerage and advice service provided by social workers may fulfil this expectation but historically this has not been on offer (there are some indications that this type of provision is now becoming increasingly available). As with the previous section these findings further highlight restrictions on the ability of individuals to make informed

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choices about their care. Those better able to negotiate their way through this system are (as Glendinning (2008) comments) better able to access support. We also heard that different providers will place different limits on the type of work they will undertake as in personal care such as washing and dressing or help with household tasks. Knowing which agency is funded to provide support or can provide support on payment or assessment is critical to understanding what help can be given and for how long. The rigidity of the boundaries between services increases the difficulty of accessing and managing care and places greater demands on the service user to take on responsibility for self-management or to engage family members to help. With cost as the primary metric, care providers (whether in the statutory, private or charitable sectors) will reduce the flexibility and range of the services that they can provide. One interviewee described: In (the) six week care we have at the moment you get four half-hour sessions a day [y] I said “Can I have the hours more flexible and maybe have a whole day’s allowance in one go so I can go out?” [y] but no, that’s not allowed (older person, interview 17).

The effects were also seen in terms of the range and quantity of services available whether this was a refusal of additional home care visits, the threat of day-centre closures or limited provision of other opportunities for social interaction which play such an important role in promoting wellbeing. Where such services are being cut by publically funded providers there is an increasing expectation that the shortfall will be picked up by charities, community groups or individuals. This provision, termed “big society” by the coalition government takes on services from the state but allows central government to distance itself from any blame for failings of provision (Grimshaw and Rubery, 2012). It highlights the effects that McGregor (2013), Fine (2007) and England (2010) refer to: that the scope of services is under threat as a result of managerialist reforms that prioritise short-term cost savings and efficiency over quality of care and longer term judgements about the value of care services. Taking responsibility for managing care There was considerable discussion concerning the responsibility for providing care. Many respondents, particularly those in the “fourth age” or moving towards dependency saw family as having the first responsibility for supporting or managing care with formal providers stepping in where the family cannot. Whilst some relished opportunities to maintain as much control and independence as possible others did not. Some participants rejected the idea of formal providers “invading” their home to provide care. Most common though, was an acceptance that family would provide some help, most usually with domestic tasks such as cooking, cleaning, washing and shopping. Most participants recognised that state-funded support would be limited with several contributors discussing the impact of funding cuts and public-sector budgetary pressures. There was, however, a clear distinction in terms of flexibility between state-funded care and that received by those able to (or required to) pay for care services. One interviewee commented “If you have money you can actually buy a lot of things, you can buy a lot of services”. A sense of personal responsibility, of maintaining independence and an acknowledgement of interdependence were all in evidence throughout the interviews, particularly for those just beginning to experience a change in their circumstances. For many, this still meant being able to call on friends and family for


small pieces of help such as shopping or access to the internet. Most participants expressed a desire to be involved in decisions that are made about them such as the decision about when to discharge from hospital where adequate involvement in making decisions about timing supported those trying to make arrangements for additional family support or for transport. Analysis revealed a difference between more active older people and those who were less active as a result of physical and/or mentally frailty. In the latter group some interviewees described a preference for staying at home to watch the world go by or regret that their social opportunities were diminishing as they grew older and became less active. These findings suggest that questions of dependence and responsibility are complex and, for the most part, highly individual. They reflect circumstances such as presence of a spouse or partner, of family and of financial situation as well as the social networks available to enhance formal services. By privileging those able to act as neoliberal independent choice-agents those that are unable or unwilling to take on the role of the independent consumer of care are further excluded. The authors’ work shows that systems and practices needed to support those least able to participate in a reformed system are currently inadequate and in an atmosphere of cost-cutting and austerity the risk is that further investment in improvements for this group of people may not be forthcoming. The implication of these findings is to question the assumption embedded in the present reforms – that individuals wish to, and are able to, act as the type of independent consumers that reformers have assumed. Whilst some older people can, and will wish to, take more control others will not feel the same way. Critically, those older people that need support with managing care must be able to access it, and must not be disadvantaged for needing this help. The findings of the authors’ research highlight how the reform agenda in England, driven by economic and demographic concerns, can impact on the way in which social care is experienced by older people. The drive towards a more business-like, managerialist, approach to delivery is already serving to threaten the capacity of some older people to access the care that they need. The personalisation agenda, with the implication that “independence” ought to be privaledged over “interdependence” places those older people with reduced capacity or desire to play an active role in decision making, or who have fewer social resources to call on for support, at a disadvantage. The discussion section that follows presents an argument for reform in the delivery of social care which places an emphasis on promoting caring relationships to support effective care. A focus on the specific needs of individuals is promoted as a more satisfactory way of ensuring high-quality care without risking further marginalisation of those in already difficult situations. Discussion: the ethic of care as response to the reform agenda This section of the paper provides a discussion to the findings described above and considers how an alternative approach to the provision of adult social care may deliver more effective services. Whilst such an approach is not specifically concerned with more efficient or less costly ways of delivering care, the “effectiveness” of solutions is a key factor in determining total cost. In the following section, the authors suggest that restructuring the system to take account of and to respond to individual needs provides a way to mitigate the impact of these reforms. The underlying assumption in this discussion is that the reforms as they are being enacted and experienced are acting


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to damage the quality of the relationship between those providing care and those that are in receipt of care. Without attending to this, the quality of care cannot be assured and therefore “effectiveness” not assured. The findings from the authors’ research, presented in the previous section, provide evidence to support a critique of two aspects of reforms to the social care system. Within the current system, those individuals that are assessed by a social care professional as meeting the requirements for access to care are given access to equal care. The emphasis on equality of care, as opposed to an emphasis on attentiveness to individual need, helps to reinforce inflexibility within the a system already rendered less flexible as a result of neoliberal reforms that promote the importance of individuality rather than caring networks or relationships. As Arendt notes “The more equal conditions are, the less explanation there is for the differences that actually exist between people; and thus all the more unequal do individuals and groups become [y] This perversion of equality from a political into a social concept is all the more dangerous when a society leaves but little space for special groups and individuals, for then the differences become all the more conspicuous” (Arendt, 1986, cited in Duffy, 2010, p. 259). By treating people equally we risk reinforcing injustices: those that are already better off will do better, those that are worse off, in need of more help or facing difficulties in accessing care, will not benefit equally. As seen above, by assuming all service users might be able to take a greater role in managing their care some, who are not able to do this, may be further disadvantaged. This conclusions points us toward an ethic of justice, whereby we turn attention to fairness, equality and the consistent application of principles (Held, 2006 cited in Noddings, 2010). We see a opposite position reflected in the policies and positions described above where rules are applied rigidly and equally to all that meet a qualifying standard – this is deemed to be “fair” but actually serves to exacerbate pre-existing injustices that result from social, health, educational or other differences between individuals. In contrast, an ethic of care demands focus on being attentive and then responsive to individuals’ needs, trust and on narrative nuance (Held, 2006 cited in Noddings, 2010). Professionals acting under such an ethical code do not therefore seek to deliver impartial, equal care to all that they work with. Rather, “what is “right” in any situation is situated and contextual” (Brannelly, 2006) with professionals responding to individual needs in a particular circumstance (Engster, 2004). In any given situation the professional may be acting in a partial manner in relation to her service user offering care options that reflect specific and individual needs. The system as a whole remains fair or just as professionals act in accordance with strictly defined rules and procedures (Holm, 2011) that are maintained through panel decision making and a system of supervision. Because the ethic of care demands understanding and responding to the needs of individuals it also emphasises the importance of human interdependence and recognises the limits of autonomy (England, 2010). It rejects the neo-liberal assumption of individuals as rational choice-agents and recognises complexity, difference and heterogeneity. Relationships between the cared-for and the one-caring promote the efficacy of the care: it is easier to be attentive to the needs of an individual that you already know well, hence care offered by family and friends can be so effective (as evidenced in our study). The relationship between attentiveness and relationships is also stressed by Klaver and Baart (2011) and by Van Heijst (2005 and 2008, cited in Klaver and Baart, 2011). The reforms of social care that seek to move service users


towards becoming consumers of care can threaten this relationship as the consumer seeks to calculate “the quality of care in relation to its price” (ter Meulen, 2008). Leece (2010) saw that the introduction of direct payments by adults with disabilities to their carers affected (not exclusively in a negative way) the quality of the relationship between one-caring and cared-for. Whilst it cannot completely counter the impact of the reforms, using an ethic of care to guide the management response to social care reform could help to insulate against negative effects. Whilst individuals provide care (not institutions) we understand that “institutions and large groups can create the conditions under which caring-for can flourish” (Noddings, 2010). Equally, the way that institutions are guided, managed and structured can promote, or inhibit, the type of relationships that are advocated here. We might therefore, in a caring organisation, expect to see attentiveness to individual needs and circumstances, decision making that seeks to reduce inequalities between individuals and active promotion of caring relationships that effectively delivery care. These are in direct opposition to the one-size-fits-all approach currently in place. Social workers are ideally placed to provide this sort of care and support as they “create venues for people who are disenfranchised to exercise power, to enhance their social competence, and to realize the benefits of an expanded base of societal resources and opportunities” (Miley and DuBois, 2007). To do so, they must be adequately supported within an organisation that recognises and understands the difficulty of the work that they are doing and which deliberately seeks to mitigate these challenges. Within caring organisations Tronto (2013) argues that attention should be paid to the principles of purpose, power and particularity that these should be valued and promoted in order to support the work of those within organisations that deliver care. If this is achieved, then those within the “caring organization” understand the role that they are to undertake; are conscious of and attentive to power and obligation in their relationships; and acknowledge the importance of behaving in a particular manner, responsive to the needs of individuals. This is particularly important in supporting those who have limited support available to them to manage their way through the complexities of the social (and health) care system. Tronto’s principles of a caring organisation (2013) are helpful in looking at organisations in isolation, but we must recognise that this is an over-simplification of the actual situation. Organisations that deliver care do so in partnership with others and in a system controlled by, and subject to the political will of, central government. As an example, the authors have already described the impact of a concentration on cost-cutting on the way caring organisations structure and deliver their care. However, an overarching and useful concept in this debate about making institutions more caring is Kittay’s (1999) concept of “nested dependencies” and “sets of nested obligations, based on the notion that care receiving is an entitlement for care givers as well as those with the primary need for care and is not part of a reciprocal exchange, but a connection-based chain of obligations”. In relation to the carer, Kittay (1999) argues that “the dependency worker is entitled not to a reciprocity from the charge herself, but to a relationship that sustains her as she sustains her charge” (p. 68). Research has for some time shown how social workers, as “formal carers” are often not adequately cared for by employing organisations and this can affect their mental health (Stanley et al., 2007) and how the needs of informal carers have been inadequately acknowledged through statutory services (Arksey and Glendinning, 2007; Seddon et al., 2007), which can again affect their mental health (Butterworth et al., 2010; Carers Scotland, 2011). Munro’s (2011) influential report into child protection


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social work in England notes the lack of support and stressful conditions that can characterise the experiences of social workers working in local authority Children’s Services and emphasises the need for organisations providing these services to “listen to the front-line” and for managers to refrain from making decisions that undermine the work of social workers, but rather support them in a number of ways, including reflective supervision, to do their job effectively (pp. 106-107 and 115). This is an example of a “nested dependency”, where social workers carrying out complex work with families require care and support themselves to retain their “partiality” towards service users, to appreciate and address nuanced differences between service users’ situations and to explore the implications of responding to particular circumstances and needs. A good working environment and effective supervision which acknowledges the emotional work involved (Morrison, 2007) is an important expression of this entitlement to care, which has been undermined by a managerialist approach to the delivery of services in social care (Wilson et al., 2011). Without paying close attention to this the capacity of social workers to consistently provide the type of care required will be limited – attention must be paid not only to what social workers do but to how they are supported to do it. Care is a fundamental aspect of all human experience, with requirements for care and support becoming more or less intense as a result of periods of mental or physical illness (Armstrong, 2006) but in relation to welfare services it is often only seen publically as being the requirement of the poor, weak and needy and as such often characterised as a demand, drain on or expense for others. A larger vision is required that eschews the illusion that life is all about separate individuals and that the unknown “other” need not concern us. Using the insights produced by care ethicists (Kittay, 1999; Noddings, 2003; Tronto, 1993), a revaluing of care at a policy level is required that acknowledges the importance of relationship, and inter-dependency as a part of normal, everyday human experience. A system is required that properly rewards the complex skills involved in giving care (skills which express the underlying attitudes of attentiveness, empathy, etc.), and recognises that receiving care is something that happens to everyone and should not be perceived as a burden to others, either to individuals or to the state. There needs to be a much fairer arrangement between the generations so that moral and political questions about old age and how we support the needs it generates are addressed. This of course requires a more collective sense of responsibility and recognition of the human imperative to address the suffering of others – including strangers who are “distant” from oneself and family. If this is to be achieved then the current political mind-set and policy trajectory will need to be challenged and the financial costs to all will need to be faced. Reforms to the provision of social care for older people in England present two distinct threats to the quality of relationships between those providing the care and those receiving (or in need of) care. Attempts to reduce the short-term costs of the social care system and neo-liberal attempts to reconceive social care service users as consumers disadvantage some groups of older people and risks disadvantaging many more. The authors’ study reveals the practical impact of these reforms for both service users and care-givers. A focus on promoting caring relationships which allow for professionals to support the needs of individuals offers a way to improve the quality of care provided for older people. It specifically seeks to avoid the delivery of standard care packages which fail to acknowledge and respect the differences between individuals. Whilst the ambition of reforms that seek to give service users more control over the care they receive through personalised budgets goes some way to addressing


this concern the suggested approach mitigates the risk of groups of older people becoming marginalised in this process. In empowering social workers and other professionals to respond to individual needs those unable or unwilling to take control over their own care plan are not disadvantaged. References Age Concern (2011), Living on a Low Income in Later Life, available at: www.ageuk.org.uk/ Documents/EN-GB/For-professionals/Research/Living_on_a_low_income_full_report. pdf?dtrk¼true (accessed 19 May 2013). Arendt, H. (1986), The Origins of Totalitarianism, Andre Deutsch, London. Arksey, H. and Glendinning, C. (2007), “Choice in the context of informal caregiving”, Health and Social Care in the Community, Vol. 15 No. 2, pp. 165-175. Armstrong, A.E. (2006), “Towards a strong virtue ethics for nursing practice”, Nursing Philosophy, Vol. 7 No. 3, pp. 110-124. Association of Directors of Adult Social Services (ADASS) (2013), “Budget Survey 2013”, London, available at: www.adass.org.uk/index.php?option¼com_content&view¼article &id¼914&Itemid¼489 (accessed 21 May 2013). Beresford, P. (2007), “State of independence”, Guardian, 23 May, available at: www.guardian. co.uk/society/2007/may/23/socialcare.comment (accessed 27 May 2013). Brannelly, T. (2006), “Negotiating ethics in dementia care: an analysis of an ethic of care in practice”, Dementia, Vol. 5 No. 2, pp. 197-212. Braun, V. and Clarke, V. (2006), “Using thematic analysis in psychology”, Qualitative Research in Psychology, Vol. 3 No. 2, pp. 77-101. Butterworth, P., Pymont, C., Rodgers, B., Windsor, T.D. and Anstey, K.J. (2010), “Factors that explain the poorer mental health of caregivers: results from a community survey of older Australians”, Australian and New Zealand Journal of Psychiatry, Vol. 44, pp. 616-624. Cabinet Office (2010), “Building the big society”, available at: www.cabinetoffice.gov.uk/news/ building-big-society (accessed 12 April 2013). Care Quality Commission (2011), State of Care Report 2010/11, Care Quality Commission, London, available at: www.cqc.org.uk/sites/default/files/media/documents/state_of_care_ 2010_11.pdf (accessed 21 May 2013). Carers Scotland (2011), “Sick, tired and caring: the impact of unpaid caring on health and longterm conditions”, available at: www.carersuk.org/professionals/resources/research-library/ item/485-sick-tired-and-caring (accessed 12 May 2013). Corbett, S. and Walker, A. (2013), “The big society: rediscovery of the ‘social’ or rhetorical fig leaf for neo-liberalism?”, Critical Social Policy, Vol. 33 No. 3, pp. 451-472. Department of Work and Pensions (2005), Older People in Low-Income Households, The Stationary Office, London. Duffy, S. (2010), “The citizenship theory of social justice: exploring the meaning of personalisation for social workers”, Journal of Social Work Practice, Vol. 24 No. 3, pp. 253-267. Elkins, T. (2012), “Local authorities and the voluntary and community sector: investigating funding and engagement”, Compact Voice, December, available at: www.compactvoice. org.uk/sites/default/files/foi_2012_-_local_authorities_report_final.pdf (accessed 5 January 2013). England, K. (2010), “Home, work and the shifting geographies of care”, Ethics, Place & Environment, Vol. 13 No. 2, pp. 131-150. Engster, D. (2004), “Care ethics and natural law theory: toward and institutional political theory caring”, The Journal of Politics, Vol. 66 No. 1, pp. 113-135.


JHOM 28,5


670

Equality and Human Rights Commission (2011), Close to Home: Older People and Human Rights in Home Care, Equality and Human Rights Commission, London, available at: www.equalityhumanrights.com/uploaded_files/homecareFI/home_care_report.pdf (accessed 21 May 2013). Estes, C.L., Biggs, S. and Phillipson, C. (2003), Social Theory, Social Policy and Ageing. A Critical Introduction, Open University Press, Buckingham. Ferguson, I. (2007), “Increasing service user choice or privatising risk? The antimonies of personalisation”, British Journal of Social Work, Vol. 37 No. 3, pp. 387-403. Ferguson, I. (2012), “Personalisation, social justice and social work: a reply to Simon Duffy”, Journal of Social Work Practice, Vol. 26 No. 1, pp. 55-73. Fine, M.D. (2007), A Caring Society? Care and the Dilemmas of Human Service in the 21st Century, Palgrave, Basingstoke. Fotaki, M. (2011), “Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers in health and social care in England and Sweden”, Public Administration, Vol. 89 No. 3, pp. 933-955. Foster, M., Harris, J., Jackson, K., Morgan, H. and Glendinning, C. (2006), “Personalised social care for adults with disabilities: a problematic concept for frontline practice”, Health and Social Care in the Community, Vol. 14 No. 2, pp. 125-133. Gilbert, T. and Powell, J. (2012), “The place that social policy plays in shaping the social context of older people”, in Davies, M. (Ed.), Social Work with Adults, Palgrave, Basingstoke. Glendinning, C. (2008), “Increasing choice and control for older and disabled people: a critical review of new developments in England”, Social Policy and Administration, Vol. 42 No. 5, pp. 451-469. Grimshaw, D. and Rubery, J. (2012), “The end of the UK’s liberal collectivist social model? The implications of the coalition government’s policy during the austerity crisis”, Cambridge Journal of Economics, Vol. 36 No. 1, pp. 105-126. Harvey, D. (2007), A Brief History of Neo-liberalism, Oxford University Press, Oxford. Heijst, A.V. (2005), Menslievende zorg. Een ethische kijk op professionaliteit (Professional Loving Care. An Ethical View on Professionality), Uitgeverij Klement, Kampen (in Dutch). Heijst, A.V. (2008), Iemand zien staan. Zorgethiek over erkenning (Seeing someone. Ethics of care on recognition), Uitgeverij Klement, Kampen, (in Dutch). Held, V. (2006), The Ethics of Care: Personal, Political and Global, Macmillan, New York, NY. HM Government (2007), Putting People First, The Stationary Office, London. Holm, S. (2011), “Can ‘giving preference to my patients’ be explained as a role related duty in public health care systems?”, Health Care Analysis, Vol. 19 No. 1, pp. 89-97. Hood, C. (1991), “A public management for all seasons”, Public Administration, Vol. 69 No. 1, pp. 3-19. Johns, R. (2011), Social Work, Social Policy and Older People, Learning Matters, Exeter. Kings Fund (2013), “How is the health and social care system performing?”, Kings Fund, London, available at: www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/quarterlymonitoring-report-feb2013.pdf (accessed 20 May 2013). Kittay, E.F. (1999), Love’s Labour. Essays on Women, Equality and Dependency, Routledge London. Klaver, K. and Baart, A. (2011), “Attentiveness in care: towards a theoretical framework”, Nursing Ethics, Vol. 18 No. 5, pp. 686-693. Leadbeater, C., Bartlett, J. and Gallagher, N. (2008), Making it Personal, Demos, London. Leece, J. (2010), “Paying the piper and calling the tune: power and the direct payment relationship”, British Journal of Social Work, Vol. 40 No. 1, pp. 188-206.


Leece, J. and Leece, D. (2011), “Personalisation: perceptions of the role of social work in a world of brokers and budgets”, British Journal of Social Work, Vol. 41 No. 2, pp. 204-223. Leung, T. (2011), “Client participation in managing social work service – an unfinished quest”, Social Work, Vol. 56 No. 1, pp. 43-52. Lymbery, M. (2010), “A new vision for adult social care? Continuities and change in the care of older people”, Critical Social Policy, Vol. 30 No. 1, pp. 5-26. McGregor, K. (2013), “Non-payment of travel time for care workers ‘breaks minimum wage laws’”, Community Care, available at: www.communitycare.co.uk/articles/20/03/2013/ 119021/non-payment-of-travel-time-for-care-workers-breaks-minimum-wage-laws.htm (accessed 27 June 2013). Mahon, R. and Robinson, F. (2011), “Introduction”, in Mahon, R. and Robinson, F. (Eds), Feminist Ethics and Social Policy: Towards a New Global Political Economy of Care, UBC Press, Vancouver, pp. 1-17. Mid Staffordshire NHS Foundation Trust (2013), “Report of the Mid Staffordshire NHS foundation trust public inquiry February 2013”, available at: www.midstaffspublicinquiry. com/report (accessed 6 August 2013). Miley, K. and DuBois, B. (2007), “Ethical preferences for the clinical practice of empowerment social work”, Social Work in Health Care, Vol. 44 Nos 1-2, pp. 29-44. Morrison, T. (2007), “Emotional intelligence, emotion and social work: context, characteristics, complications and contribution”, British Journal of Social Work, Vol. 37 No. 2, pp. 245-263. Munro, E. (2011), The Munro Review of Child Protection: Final Report – A Child-Centred System, The Stationary Office, London, available at: www.official-documents.gov.uk/document/ cm80/8062/8062.pdf (accessed 24 June 2013). Noddings, N. (2003), Caring: A Feminine Approach to Ethics and Moral Education, University of California Press, Cambridge, MA. Noddings, N. (2010), “Moral education in an age of globalization”, Educational Philosophy & Theory, Vol. 42 No. 4, pp. 390-396. Norman, J. (2010), The Big Society. The Anatomy of the New Politics, University of Buckingham Press, Buckingham. Paulsen, J. (2011), “A narrative ethics of care”, Health Care Analysis, Vol. 19 No. 1, pp. 28-40. Pearl, J. (2012), “Which? Exposes failings in home care system. Shocking examples of poor care of older people”, London, available at: http://conversation.which.co.uk/consumer-rights/ home-care-investigation-elderly-people/#more-25630 (accessed 21 May 2013). Phillips, J. and Waterson, J. (2002), “Care management and social work. A case study of the role of social work in hospital discharge to residential or nursing home care”, European Journal of Social Work, Vol. 5 No. 2, pp. 171-186. Phillipson, C. (2006), “Aging and globalisation: issues for critical gerontology and political economy”, in Baars, J., Dannefer, D., Phillipson, C. and Walker, A. (Eds), Aging, Globalisation and Inequality, Baywood Publishing Company, New York, NY. Phillipson, C. (2008), “The frailty of old age”, in Davies, M. (Ed.), The Blackwell Companion to Social Work, 3rd ed., Blackwell Publishing, Oxford. Powell, M. (2000), “New labour and the third way in the British welfare state: a new and distinctive approach?”, Critical Social Policy, Vol. 20 No. 39, pp. 39-60. Rogowski, S. (2010), Social Work: The Rise and Fall of a Profession, Policy Press, Bristol. Roulstone, A. and Morgan, H. (2009), “Neo-liberal individualism or self-directed support: are we all speaking the same language on modernising adult social care?”, Social Policy and Society, Vol. 8 No. 3, pp. 333-345. Sarantakos, S. (2005), Social Research, 3rd ed., Palgrave Macmillan, Basingstoke.


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Scourfield, P. (2007), “Social care and the modern citizen: client, consumer, service user, manager and entrepreneur”, British Journal of Social Work, Vol. 37 No. 1, pp. 107-122. Seddon, D., Robinson, C., Reeves, C., Tommis, Y., Woods, B. and Russell, I. (2007), “In their own right: translating the policy of carer assessment into practice”, British Journal of Social Work, Vol. 37 No. 8, pp. 1335-1352. Slasberg, C., Beresford, P. and Schofield, P. (2012), “How self directed support is failing to deliver personal budgets and personalisation”, Research, Policy and Planning, Vol. 29 No. 3, pp. 161-177. Stanley, N., Manthorpe, J. and White, M. (2007), “Depression in the profession: social workers’ experiences and perceptions”, British Journal of Social Work, Vol. 37 No. 2, pp. 281-298. Stepney, P. (2006), “Mission impossible? Critical practice in social work”, British Journal of Social Work, Vol. 36 No. 8, pp. 1289-1307. Stevens, M., Glendinning, C., Jacobs, S., Moran, N., Challis, D., Manthorpe, J., Fernandez, J.-L., Jones, K., Knapp, M., Netten, A. and Wilberforce, M. (2011), “Assessing the role of increasing choice in English social care services”, Journal of Social Policy, Vol. 40 No. 2, pp. 257-274. ter Meulen, R. (2008), “The lost voice: how libertarianism and consumerism obliterate the need for a relational ethics in the national health care service”, Christian Bioethics: Non-ecumenical Studies in Medical Morality, Vol. 14 No. 1, pp. 78-94. Tronto, J. (1993), Moral Boundaries: A Political Argument for an Ethic of Care, Routledge, London. Tronto, J. (2010), “Creating caring institutions: politics, plurality and purpose”, Ethics and Social Welfare, Vol. 4 No. 2, pp. 158-171. Tronto, J. (2013), “Creating caring institutions: politics, plurality and purpose”, in Koggel, C.M. and Orme, J. (Eds), Care Ethics. New Theories and Applications, Routledge, London. Tsui, M. and Cheung, F. (2004), “Gone with the wind: the impacts of managerialism on human services”, British Journal of Social Work, Vol. 34 No. 3, pp. 437-442. Wilson, K., Ruch, G., Lymberry, M. and Cooper, A. (2011), Social Work. An Introduction to Contemporary Practice, 2nd ed., Pearson, Harlow. Further reading Appleby, J., Humphries, R., Thompson, J. and Galea, A. (2013), “How is the health and social care system performing?”, Kings Fund, London, available at: www.kingsfund.org.uk/ publications/how-health-and-social-care-system-performing-february-2013 (accessed 12 April 2013). Carr, S. and Dittrich, R. (2008), Personalisation: A Rough Guide, Social Care Institute for Excellence, London. HM Treasury (2010), Spending Review 2010, The Stationary Office, London, available at: http:// cdn.hm-treasury.gov.uk/sr2010_completereport.pdf (accessed 12 May 2013). Lymbery, M. (2004), “Managerialism and care management practice with older people”, in Lymbery, M. and Butler, S. (Eds), Social Work Ideals and Practice Realities, Palgrave, Basingstoke. Ruch, G., Turney, D. and Ward, A. (2010), Relationship-based Social Work: Getting to the Heart of Practice, Jessica Kingsley, London. About the authors Dr Will Thomas is a Lecturer in the School of Business, Leadership and Enterprise and is a Course Leader for the MSc Sustainable Business. His main interest is in working to sustain


and promote strong communities through work with the private, public and third sectors. He has a background in public policy, social policy and social care and experience of working on a number of projects looking at integrated services and service user experiences of care systems. He holds a PhD in Philosophy from the University of Essex. Dr Will Thomas is the corresponding author and can be contacted at: [email protected] Dr Sue Hollinrake is a Senior Lecturer and Programme Leader for the BA (Hons) Social Work at the University Campus Suffolk. She is a qualified Social worker and also holds the Post Qualifying Advanced Award in Social Work. Sue has many years’ experience as a social work practitioner and manager in local authority, statutory social work and has taught social work for the last 16 years. She is a Doctor of Social Work (University of East Anglia) and her research interests include service user and carer experiences and social work with adults.

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