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.
Usually when I get asked to speak, it is on a specialist subject. Yesterday, for example I had a great time delivering the Edward Boyle Memorial Lecture, on twenty first century enlightenment, to Fellows and some non Fellows in Leeds. It is still more challenging when I am asked to speak on a topic which goes beyond my current (limited) expertise. As the date of the event approaches I get into a spin and rely heavily on the ‘idiot’s guides’ churned out by Ben Dellot from our Projects team, who doubles up as my occasional research assistant. But it also means I have to become reasonably informed about a new topic and, sometimes, it spurs me into thinking about whether there is any scope for a wider RSA intervention.
Tonight I am speaking at the National Care Forum annual review and this has got me doing some thinking about the future of care. I won’t bore readers with my whole argument but I thought there might be some interest in one key point.
I am going to argue that we need many kinds of innovation if we are to close the care gap (between what individuals and the state can afford and what is needed). The gap is already widening as local authorities withdraw all but essential care and the Centre for Social Justice said this week it will grow by an additional £6 billion over the next two decades.
The areas of invention which most interests me tend to be at the intersection of three trends. First, the growth in personal and community based commissioning (Turning Point are doing some great work on the latter). Second, the search for ways of bridging and smoothing the divide between paid and unpaid care. Third, new ways of thinking about the economics of care, utilising not just money but other commodities such as time and housing.
There is a danger the audience will have heard of all of these but I am going to describe three ideas which I think are particularly powerful pointers to the direction we need to take if we are better to tap into the ‘hidden wealth’ of people’s willingness to share, care and connect.
The basic unit of account is an hour of service to an elderly person. Sometimes seniors help each other and earn the credits, other times family members in other communities earn credits and transfer them to their parents who live elsewhere. For example, an elderly woman who no longer has a driver’s license; if you shop for her, you get credit for that, based on the kind of service and the number of hours. These credits accumulate- users may keep them for when they become sick or elderly themselves, then use the credits in exchange for services. Alternatively, the users may transfer credits to someone else.
An interesting lesson from the project has been that the elderly tend to prefer the services provided by people paid in the tickets over those paid in yen.To convert this community service to yen would seem to dilute the community ethic.
Closer to home there is Southwark Circles of Care, the flagship in a network of ‘Circles’ that extends to Hammersmith & Fulham in West London and just last month to Suffolk County Council. The concept and business model has been co-designed and developed over three years with over 1,000 older people and their families, in conjunction with the cutting edge service design consultancy, Participle.
The service is delivered by a distributed network of people called Neighbourhood Helpers. These are people of all ages who share their talents and skills; many are also members and some are paid the London Living wage for their time. Each Circle is designed to be self-sustaining within a three-year launch period, and is supported by the Local Authority as it grows towards this milestone.
Third, Shared Lives and Homeshare which are both initiatives developed and supported by NAAPS. Shared Lives is where an individual or a family chooses to include an isolated or under-supported older or disabled person in their family and community life. In many cases that person becomes a permanent part of a supportive family.
There are around 10,000 SL carers in the UK, of which 3,800 are NAAPS members. Shared Lives is unique in adult support, in that Shared Lives carers are paid a flat rate (like a foster carer) rather than by the hour, are expected to form two-way relationships including mutual links to family and social networks (as opposed to the highly boundaried, one-way “professional” support relationship), and because Shared Lives is based on matching individuals who need support with compatible Shared Lives carers and families.
Homeshare involves someone who needs some help to live independently in their own home being matched with someone who has a housing need and can provide a little support. “Householders” are often older people who own or are tenants in their own home but have developed some support needs or have become isolated or anxious about living alone. “Homesharers” are often younger people, students, or key public service workers who cannot afford housing where they work.
Sometimes ideas like the Big Society, hidden wealth and socially productive public services seem abstract but in these examples we can see a clear outline of the services of the future.
PS Because the splendid Clifford Longley is trapped in the snow I have just had an emergency call to join the panel for Moral Maze. The topic – should we be trying to live forever? Having prepared for my speech tonight the prospect of a long old age seems just a bit less daunting.
‘Tax increases and spending cuts are inevitable immediately after the election….’
‘any managers of a public service who are not planning now on the basis they will have substantially less money to spend in two years time are living in cloud cuckoo land’
This message chimes with the detailed picture drawn last week for the 2020 Public Services Trust Commission (here at the RSA) by IFS Director Robert Chote. Put simply, we are talking about a period of at least three years, starting next year, in which public spending budgets will be squeezed more tightly than in the living memory of most public servants.
Which means three issues should be getting focussed attention in the public sector – but I see little sign of any even being seriously discussed.
First, we need to be exploring the scope for major productivity gains, not just cutting back office staff, but re-engineering services to achieve substantial cuts in costs. The example I have given in the past involves schools moving to a four day taught week for key stage four pupils with the fifth day being used for self guided study. With the right use of space, on-line tuition and teaching support this could make a substantial saving on teaching time and also be good for pupils. Another example is that if local authorities moved more boldly on individual budgets, putting in place the technological and community support necessary to do so, they should be able radically to reduce case and middle management costs in adult service departments.
Second, we need to be encouraging an intensified process of innovation in public services, designed to find ways of doing the same, or more, for less. There are many organisations out there, from Participle to Think Public to the Design Council (indeed the RSA itself) with expertise in citizen-led public sector innovation, but their work still tends to be at the margins. They need to be given more support and be incentivised to collaborate better.
Third, we need a frank and creative discussion between policy makers, practitioners and the public about the hard choices to be made over the coming years. Local residents may complain about moving to fortnightly refuse collection but they might feel differently if they understood this was one of the measures that enabled the council to protect other services. The creative question here is how could the actions of citizens themselves reduce spending pressures and enhance service outcomes?
These kinds of debates should be taking in every Government department and local authority. If public services don’t adapt, innovate and engage the public in new ways we face a demoralising and divisive era of cuts which will not only damage people’s lives but could fatally undermine voters’ faith in universal public provision.