Hardly a day goes by without a new story about the crisis of care. Yesterday a report from the Daycare Trust highlighted the continuing and deepening problems of childcare affordability. Costs are highest in London, where the average cost of a full time nursery place for a child under two is now £14,000 per annum. Provision beyond the school day for older pupils is also becoming much more expensive.
Today there was research from Carers UK showing that more than one in five adults have seen their work affected by caring responsibilities. An estimated 2.3 million people in the UK – among whom the hardest hit are 45-54 year olds – have left jobs to care for a loved one, with many more reducing their hours. And just in case we thought the problem was all about quality not quantity there is this reminder from Wales of the frequency of scandals in care settings.
As I said in an earlier post, society’s capacity for providing care is a diamond comprising the market, the state, close family and the wider community. Thinking about how to generate more and better care involves looking at the contribution from each source but also, more importantly, understanding the relationship – sometimes additive sometimes subtractive – between them.
Arguably, for example, the problem of informal care by families is oversupply. As the Daycare Trust and Carers UK are pointing out, the need to provide care and the costs of buying it are the crucial factor inhibiting maternal employment and increasingly important in keeping older people from full time work.
Voluntary care by the wider community is by far the least substantial of the major sources of care. But is has a vital advantage; unlike the other sources, increasing it does not have problematic knock-on effects.
So how might we go about achieving a step change in the contribution made by the community? As with all complex social problems, the best solutions combine the forces of individual aspiration, collective values and hierarchical leadership and capacity.
This suggests a number of ingredients:
Incentivised volunteering: there is often a false dichotomy between paid and voluntary labour. In fact, small incentives – well below – market value can be enough to persuade someone to do something which gives the non-material reward of pride and satisfaction. I think, for example, the debate about the possibility of providing some remuneration to school governors is entirely welcome. As well as various ways of giving people rewards for volunteering, one idea might be to link the need for care to another great and growing need – affordable housing. How about providing a fast track to social housing for people who agree to give a certain number of hours of care to neighbours?
Structured reciprocity: Perhaps I am being unfair but despite a hundred and one experiments, it remains to be seen whether time banking can make a really big and sustained impact on community capacity. Most people’s reaction to the Japanese scheme in which people who have moved away from their ageing parents ‘swap‘ responsibility for supporting them is that it wouldn’t work in our culture. So although it must be part of the solution there is still some way to go in finding ways of building reciprocal capacity.
New norms: I have written before of my idea of a national young people’s care service. Whatever anyone thinks of that we need to explore how we can make helping to look after people other than ones loved ones as normal and common as, say, spending time getting fitter.
Enabling regulation: We all know how the necessary measures to ensure child safety have acted as real and perceived block to voluntary work with kids. We need forms of hard and soft regulation which are developed to make it easier and less risky to care. For example, (I know Alex Fox will correct me if I am wrong) I think one part of the Shared Lives scheme in which families offer support to adults with problems is a guarantee that if things go wrong the charity will relieve the family of its responsibilities no questions asked.
In all these areas technology, and especially big data and social media, could play an important role in innovation.
There are elements of all these ideas happening somewhere in Britain or around the world. The problem is finding sufficient investment, commitment and patience to take new ideas for voluntary care to scale. But unless the alarming headlines are to continue indefinitely we really have no choice but to keep trying.
A society’s capacity for providing care (which, as one reader pointed out to me, is not the same as how much it cares) can be seen as a diamond comprising the market, the state, close family and the wider community.
Thinking about how to generate more and better care involves looking at how we might increase the contribution from each source but also thinking about the relationship – sometimes additive sometimes subtractive – between them.
Care funded by the state is perhaps the most straightforward to analyse in the sense that it is fully stretched and it is difficult to see any significant increase in capacity in the foreseeable future. In terms of the overall pattern, the last decade has seen an increase in state support for child care (although under the Coalition it has been a case of swings and roundabouts as the child care element of tax credits has been reduced but the entitlement to nursery provision has increased). In relation to adults and older people, some national care-related entitlements have been tightened while at the local level provision is now limited to the most needy.
The market for care is also very stretched. The private provision of care is expanding in line with need but in all domains of care there is a major affordability gap between what the market can offer – even paying rock bottom wages – and what most people can afford. Austerity is also putting ever greater pressure on the publicly funded aspects for private care. For example, there is a growing gap between the cost the private sector charges self-funding clients of residential care and what it is able to charge increasingly cash strapped local authorities. Coalition ministers had expressed the hope that the implementation of a new long term care funding framework could create an opportunity for a new care insurance market to emerge. But such hopes have been expressed – and dashed – before.
When it comes to families the top line is that informal familial care is the bedrock upon which the whole societal care system rests. On the one hand, nearly all parents enthusiastically provide loving care for their children; on the other, a recent ONS analysis of the 2011 census estimated the total weekly provision of informal adult care in England and Wales at 3.4 million working days (up substantially on ten years ago). In rough terms, valuing an hour of unpaid care at the minimum wage level this means that unpaid care is worth about £170 million per week or about £8.5 billion per year. In fact the value is much greater as those cared for at home are also being housed and fed by their loved ones.
Arguably the problem of informal care by families is oversupply. While parental negligence and ‘granny dumping’ is still very rare, some care, both for children and adults, is not as good as it could be if informal provision was mixed with formal care. Vitally for the economy, levels of employment of mothers and people over fifty are lower in the UK than many other advanced economies. The need to provide care and the costs of buying it are the crucial factor inhibiting mother’s employment and an increasingly important factor keeping older people from full time employment.
This leaves the fourth point of the diamond, the community. We might define this as the contribution voluntarily made by people other than close family to the provision of care. This primarily comprises volunteer time but other contributions include money (in the form of philanthropy), the provision by employers of flexible working and, more generally, the framework of norms and values which shape the status of caring and the degree to which we see it as a collective responsibility.
In relation to this aspect today sees two contrasting contributions. This Guardian piece from Erin Mee http://www.guardian.co.uk/society/2013/feb/26/care-workers-plea-older-people-lonely underlines how much unmet need for even for the simplest forms of care there is lurking in every community. NESTA has today published a new report on a system response to , the Endowment is also calling for new ideas for its website celebrating innovative responses to ageing .
As NESTA says, many innovations can work alone and do not require or benefit from a system wide approach. But, as the report also says, despite lots of activity and concern about ageing social innovation is lagging behind technological innovation and we have a very fuzzy idea of what actually works, which is perhaps why we need to shift our whole orientation. But if we do need to look at the system, what is the system? Is it the system of ageing, the system of care, or more narrowly the system of older care and the system of child care?
My feeling now is that, firstly, there is something essential to the human activity of providing all forms of care, and, secondly, there are common issues and dilemmas in the mixed systems of care which apply to children, adults and elders. This is why it is caring which should be the focus of our system view rather than a particular demographic group.
But, as is always the case when I start thinking in earnest about my annual lecture, I may well change my mind several times before I reach any kind of conclusion.
I am spending a lot of time right now thinking about care and the genuine crisis we face in providing enough of it – either voluntarily or at the right price and right quality – to the people like the very young and the old and frail who need it. Unlike other crises this one is impacting here and now, as well as being likely to get worse in the future. At this stage all I have to offer is some speculation, but I have been grateful for some lively comment on earlier posts addressing this topic and I am on the lookout for more guidance.
There are big challenges in even trying to frame the care debate. There is the problem of definition as care can mean anything from the concrete questions of state provision and funding mechanisms to the general capacity of a society for altruism and compassion. There is ambivalence about whether care is a primarily matter of social policy or of personal choice and responsibility. We pay people to care, we train people to care, we encourage people to care yet the whole point about care is that it should be freely given as part of what Avner Offer calls ‘the economy of regard’. Also, I am in no doubt that feminist economists are right that care fails to get the social status and academic attention it deserves because it is seen as ‘women’s work’.
Yet, we must try to get a better and more rounded grasp of care situating concrete policy debates in a more engaging conceptual and normative framework.
It may be that it is a mistake to think about child care and social care together. Whilst they feel like very different things (one associated with joy, the other with misfortune) in both areas there are issues of supply, affordability, quality, status and employment impact (on individuals and the wider economy). At the heart of both are these key issues:
Risk – having children is a good risk while needing social care is a bad risk (although, as Woody Allen said, the only good thing about getting old is that it’s better than the alternative) but they are both financial risks. How should the burden of that risk be distributed between the individual and family, society and the state?
Benefit – when we provide care are we merely benefitting the recipients of the care as a private act (which should be largely unregulated and unrewarded) or are we performing a task for wider society?
Responsibility – there is an apparent contrast between having children, which we choose and needing social care, which is generally as a result of a misfortune that befalls us. Yet, in both cases we make all kinds of decisions which govern the degree to which we need society and the state to step in and help us. We hear a lot of critical comment about teenage mums but much less about the decisions elders and their relatives make which increase the formers’ risk of isolation.
Of course, these are foundational issues for any review of the principles underlying the welfare state, but they are also questions whose answers must reflect changes in circumstances. In little mroe than a generation the whole care debate has been transformed by the rise of women’s paid labour and population ageing.
The way I have described things so far tends to imply this is a zero sum debate between the carer and cared for and the wider state and society (which is how the whole post-Dilnot debate was framed).
As I ponder my annual lecture, the question is whether, if we start from a different point, a more enlightening debate with new answers might emerge. As yet I am not sure what that point is.
The question ‘how do we meet society’s need for care ?’ has emerged as one of the most important and intractable we face. We need to see it as a challenge not just for policy makers or care professionals but for society as a whole and for the values and capabilities we need to thrive in the coming era.
On Monday we had an important, and in my view welcome, announcement by the Coalition, of its response to the Dilnot Commission . It is true that the new policy will not be implemented for four years and that in relation to the overall problem of social care it will only offer some help to some people, but it does at least provide a framework which can subsequently be built upon (this is often the best way to introduce policy change).
Today there is (yet) another expose of poor care standards. In this case it is the home care services and their commissioners and providers in the frame .
I am also told that on Friday the ONS will be publishing an estimate of the total value of informal care, something that will no doubt highlight how little support unpaid carers feel they receive from the state and wider society.
Fundamentally, the problem is simple: whether we are talking about children, adults or elders there is not enough free and affordable care to go around. It is a very specific example of what I have termed the social aspiration gap – separating the society we would like to live in from the one resulting from our current behaviours and attitudes.
In effect we have silently abandoned the welfare state’s promise to offer universal decency and collective insurance against predictable risks. One economic consequence is that among over fifties and mothers we have lower employment rates than many other countries and this is drag on economic performance. This problem is leading to millions of our fellow citizens suffering today and without concerted societal action things will only get worse.
There are a thousand and one ideas and initiatives to close the care gap and we have discussed many of them here at the RSA. For example, Circles of Care – which was developed by Participle is often quoted and I am a great fan of Shared Lives, but it is proving hard to scale up these and make a substantial difference to the underlying problem.
Practical innovation must continue but alongside it, indeed supporting it, we need a much bigger debate about care and society. We tend to see the care crisis as the result of the interaction of economics (public spending and market supply) and demography (ageing and the birth rate), but there are surely other factors at play.
Whatever pious words we utter, care (both formal and informal) is a low status activity. Both interpersonally and collectively we find it hard to talk honestly about the experience of caring as something which combines great rewards and satisfaction with drudgery and resentment. On Friday the ONS will come up with a big figure for the value on informal care but it is not a value you will see reflected in the national accounts. This is not unrelated to the fact that caring is seen as ‘women’s work’ and also our ambivalence about whether the child care and elder care is primarily a familial or a social responsibility.
Talking more honestly about care, enhancing our ability and willingness to provide care – not just to loved ones but as part of a wider social effort, using care – rather than the more nebulous ‘well-being’ – as a prism through which to re-examine the way we think about economic and social value: All this is necessary.
I am planning to make the care society the focus of my annual RSA lecture, and tomorrow I will float a practical idea I have to improve public attitudes and develop care capabilities.