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.
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.
Two stories of unmet social need have featured in the news in the last 24 hours. First, there was David Cameron’s announcement of matched funding to tackle the problems of dysfunctional families. Second, there is today’s report by the Royal College of Psychiatrists highlighting failings in care for patients with dementia. One aspect of these stories is the apparent fading of two key Government principles; localism and the Big Society.
Although we are told Eric Pickles fought off an even more centralised approach, the troubled families scheme will effectively mandate local expenditure on a priority chosen by central Government. The content of the scheme is also likely to be tightly specified by Whitehall. This may not be a bad thing. I am sure my old friend Louise Casey could make a strong argument both that councils should be forced to invest in this area and that there are tried and tested techniques which every scheme should apply. But this effective imposition of a priority through earmarked funds stands in contrast to Eric Pickles’ promises when he abolished Local Area Agreements, the mechanism through which councils negotiated their priorities with Whitehall.
An even more striking example of central control comes in the response of Care Services Minister Paul Burstow to the RCP report. Apparently, next year will see the introduction of a financial incentive to encourage hospitals in England to screen patients for dementia when they are admitted for other conditions. It is hard to see how this kind of micro-management fits with the promise that health commissioning will be localised.
In both cases the Government can claim it is using incentives rather than targets and regulation, but when there is too little money to go around ear marked funds are surely as powerful in driving behaviour as any target.
Also noteworthy in both these stories is the absence of an explicit role for the community in addressing problems. As I argued a few weeks ago in response to the Care Quality Commission’s findings of terrible hospital care for vulnerable elderly people, a crucial factor is the place of family, friends and volunteers providing care and advocacy which goes beyond the basics of medical treatment. I don’t have any evidence to prove my point, but I am willing to bet a substantial sum that a key variable in the quality of institutional care received by older people is simply the number of visitors they have.
The extended family and wider community also have a crucial role to play in helping troubled families. The RSA’s own work with people recovering from substance abuse addiction has developed a strategy in which service users design and help provide the services they need with a particular emphasis on engaging other individuals and organisations across their locality. The aim is to create what we call ‘a recovery community’.
An impressive example of an approach with similar principles is Shared Lives. This long established and expanding scheme involves local co-ordinators identifying and supporting families who are willing to open up their homes and lives to vulnerable people. The families get back up, advice, help if things go wrong and something towards costs, but the scheme is based on relationships not transactions, love and compassion not service requirements.
In the context of growing needs and shrinking budgets it is crucial to develop interventions which successfully blend public services and funding with self-help, co-production and community mobilisation. This should be the golden thread running through every Government public service initiative. That it is not is yet another sign of the failure of the Big Society narrative to be understood or gain traction in Whitehall.
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.