A new vision for adult social care

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2010 30: 5Critical Social PolicyMark Lymberyolder people

A new vision for adult social care? Continuities and change in the care of

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© The Author(s), 2010. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.navCritical Social Policy, 0261-0183 101; Vol. 30(1): 5 –26 341899 10.1177/0261018309350806http://csp.sagepub.com

M A R K L Y M B E R Y

University of Nottingham

A new vision for adult social care? Continuities and change in the care of older people

AbstractThe reform of adult social care is a major preoccupation within England. It is presented as the inevitable consequence of the changed expectations of people who use services; in addition, the detail of policy is portrayed as being in accordance with what those people specify they want from social care. However, there appears to be little recognition of the complexities and contradictions that characterize much of the policy. Of these, the inadequacy of the resource base of adult social care is most significant; consequently, rationing of scarce resources will continue to be a priority. The paper also highlights problems in other areas, including the rhetoric that accompanies policy change and the evidence base for that change, the lack of connection between issues of independence and protection, the partial understandings of partnership that appear to characterize it and the inadequate conceptualizations both of the nature of those people who require social care support and of the character of that support. In discuss-ing these issues, the paper emphasizes that there remain continuities in the context of policy, while noting the continual focus on discontinuity within government documents.

Key words: personalization, social care policy

Introduction

Adult social care in England is undergoing major changes. The label of ‘personalization’ has been attached to this policy (Leadbeater et al., 2008); it is suggested that the individual should be placed at the heart of service provision, in turn ensuring a maximum level of responsive-ness to what that individual desires. It is quite typical of government policy rhetoric that this apparently straightforward idea encompasses



6 C R I T I C A L S O C I A L P O L I C Y 3 0 ( 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.



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




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




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,




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;




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




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




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,




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




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.




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




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




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).




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




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




‘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:




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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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: [email protected]



A new vision for adult social care

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