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Looking at care from a different angle

February 18, 2013 by
Filed under: Public policy, The RSA 


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.

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7 Comments on Looking at care from a different angle

  1. Alex Fox on Mon, 18th Feb 2013 6:05 pm
  2. Really great to see you focusing on care in your blog Matthew. I think you are absolutely right to see this as an issue which is inseparable from wider societal and economic systems. The economy of regard and the financial economy work in different ways, but they do impact upon each other.
    I’d challenge your description of childcare as a good risk, associated with good fortune, with care and support for adults associated with things going wrong. I agree that it’s seen that way, but inherent in that world view is the assumption that disability, frailty or illness are as you say, ‘misfortunes’, whereas they are of course inevitable and should be seen as part of normal family life. There are 6 million carers in the UK (including thousands under 18), for whom providing family care has become normal life. Most say they want to care, but they want some recognition, support and balance. If we want to have children, we must accept that some of those children will be born with long term health conditions, some will acquire them during adulthood and the rest (the fortunate rather than the unfortunate!) will grow old and eventually frail.
    Care and support needs can bring suffering, but there is a risk in accepting the description you outline that all of that suffering is seen as inevitable. If we lacked decent and free children’s health and education services; if there was no such thing as child benefit, or maternity/paternity leave etc, we might associate child rearing more with hardship, because the hardship associated with adult care is partly about inadequate services, stigma, isolation and poverty due to loss of work.
    I’d also like to extend your question about who we benefit when we care for someone. You ask if we benefit just our family, or wider society. Some have argued that we also benefit ourselves. I’m always struck when I talk to Shared Lives carers, who choose to take on some very challenging caring roles for adults who move in and live with them as part of the family, that Shared Lives carers reject the notion that they are saintly. They say “He / she is just part of the family” and “It comes naturally”. They often say “I get as much out of it as he/she does”. They seem unusual, but perhaps they are just a version of normal which the rest of us have forgotten somewhere along the line (I’m not a Shared Lives carer myself and I don’t think I’d make a good one!).
    So I’d suggest the starting point you are looking for might be that needing to provide adult care is as normal and ‘neutral’ in terms of mis/fortune as providing child care. In both, there is an element of choice. In both we need support, but cannot (and should not) be paid for everything we do. In both there is a relationship between our contribution to the economy of regard and our contribution to the cash economy. In both cases, we will both receive and need care at different times in our lives. And we can only do either well and with well-being, if we and those around us value both the care we provide, and what we recieve from any caring relationship.

  3. Julie Stansfield on Tue, 19th Feb 2013 12:44 am
  4. Making a comparison between child care and adult care helps think about some
    Of The fundamental issues we need to face. As Alex details there is no real perverse incentives to abandon your children. Free real family and community child care is viewed as a higher quality of care and support for children. How lucky and privileged am I to have my parents doing child care for my daughter. When I mention we also all support my 45 year old brother I am told I shouldn’t have to do that the state should provide support and if we refuse to support him he will get more resource (and he could)
    Why is my daughter lucky to belong to our family but my brother belongs to the state?

    At what point did we start to distinguish that family who have a diagnostic support need no longer belong but those without diagnosis do?
    This is not by any means me saying that there is not a state role but the States role should be to support the family/ community to stay “in” and belonging together.

    They say it takes a whole village to raise a child and every adult needs support whether diagnostic or not. .. it takes a people network too… something that is rarely recognised by with the exception of the ordinary folk

  5. Julie Stansfield on Tue, 19th Feb 2013 12:47 am
  6. Making a comparison between child care and adult care helps think about some
    Of The fundamental issues we need to face. As Alex details there is no real perverse incentives to abandon your children. Free real family and community child care is viewed as a higher quality of care and support for children. How lucky and privileged am I to have my parents doing child care for my daughter. When I mention we also all support my 45 year old brother I am told I shouldn’t have to do that the state should provide support and if we refuse to support him he will get more resource (and he could)
    Why is my daughter lucky to belong to our family but my brother belongs to the state?

    At what point did we start to distinguish that family who have a diagnostic support need no longer belong but those without diagnosis do?
    This is not by any means me saying that there is not a state role but the States role should be to support the family/ community to stay “in” and belonging together.

    They say it takes a whole village to raise a child and every adult needs support whether diagnostic or not. .. it takes a people network too… something that is rarely recognised by the state but already there with some ordinary folk.

    Looking forward to seeing how you develop this Matthew.

  7. Brian Cox on Tue, 19th Feb 2013 2:27 pm
  8. Matthew,

    I like your emphasis on thinking differently and your focus on care. This is much needed and is urgent and very significant.

    Personally I struggle with much of the policy, economic and structural debate about care and social care because it is narrow in its scope and mislocated in its positioning. The policy thinking and the contributions from the care industry doesnt reflect my experience of working in the sector or my experience of familial and kinship care. I have recently taken to using three concepts as a foundation to thinking about the future of care. These have really helped me sort the wheat from the chaff and think afresh about how we might shape the future. I will set them out briefly in the hope that others might provide criticism and develop the points further but I should add that I do so with some humility as people like Alex and Julie have much more experience at ground breaking in this area than me.

    Firstly I think it is helpful to distinguish care from caring. Care has come to be associated with the care industry and is often used to describe a set of tasks and physical needs. Caring on the other hand is a broad concept and one that still has a wider meaning and resonance. Caring is instinctive, emotional, human and compassionate. It is something we all do and all need. Interestingly reading recent reports from Winterbourne View and Staffordshire NHS, poor quality care (badly or cruelly performed tasks) is well described but caring (love and engagement) is repeatedly neglected.

    I have to say that I dont have answer to where the proper balance between caring and care should lie.

    Secondly care is often based on a deficit model – the subject of care needs remedial help to cope with everyday life – and this deficit model is extended beyond the physical to the whole person being cared for. With the exception of the personalisation work of Julie, Alex and others, we tend to assume that these deficits are insummountable and deepen over time. This is particularly true of older people whose care is based on the assumption that declining physical and mental abilities are inevitable and furthermore that these will deminish the capacity of older people to contribute to other areas of social, economic and political life. Care becomes the vehicle by which people are gradually removed from valued roles, valued public spaces and from rich public networks.

    Your useful contrast between society’s approach to child and adult care also, in this context, hightens the distinction between our approach to growth, development and enablement of chidren and our containment, restriction and isolation of older people. Can we not take a pedagogical approach to the care of older people expanding and supporting their participation and engagement in society? Perhaps we could also expand your earlier ideas on the care experience (which I support) for younger people with an intergenerational approach inwhich older people and adults also contribute, teach and learn?

    Thirdly we need to think about care as a generic issue that affects us all not something boxed off and separate from politics, economics or social reform. One of the frustrating things about care is that many commentators and industry specialists talk as if care is another planet – except that is when they run into the care system through the experience of caring for an elderly parent. Recently I have taken to using more inclusive language when thinking and writing about the future of care not only because the realities of aging are increasingly impinging on my own conception of self but because it is no more a question for individuals and familes in the care system than, say, education is only of relevance to children. “Caring for all our futures” a phrase borrowed and adapted from Scotlands approach, is not only a sound way of conceptualising the issue but tactically way of widening and deepening the debate with the aim of arriving at a new vision and a new settlement in which we all have a stake.

  9. George on Wed, 20th Feb 2013 11:18 am
  10. The problems and challenges for caring for the weakest members in society highlights one of the challenges for the 21st century – the need for effective, ongoing metrics for social capital.

    While social capital clearly has financial value, measuring social capital in financial terms is not just inadequate it is, in fact, counter-productive. How do you put a dollar value on acts of kindness?

    Finding a metric for social capital is critically important because what we measure, we value, what we value affects how we behave and how behave is who we are.

    Without its own metric, social capital will always be seen as less valuable or just “women’s work.”

    Having a metric for social capital will result in the following:
    - Recognition of the value of social capital
    - Recognition and acknowledgement of those creating social capital
    - The harnessing of self-interest in the creation of social capital.

    All this is now made possible with the new communication technologies and new initiatives like ThankUbank – the world’s first social capital bank.

  11. Brian Cox on Wed, 20th Feb 2013 1:33 pm
  12. Matthew,

    The following is a slighlty revised version of something that I attempted to post yesterday which seems to have got lost in the ether. Apologies if two versions appear.

    I like your emphasis on thinking differently and your focus on care. This is much needed and is urgent and very significant in my view.

    Personally I struggle with much of the policy, economic and structural debate about care and social care because it is narrow in its scope and mis-located. The policy thinking and the contributions from the industry and commentators generally do not reflect my experience of working in the sector or my experience of familial and kinship care. I have think there are three concepts which I find useful in thinking about the future of care. These have really helped me sort the wheat from the chaff and think afresh about how we might shape the future. I will set them out briefly in the hope that others might provide criticism but I should add that I do so with some humility as people like Alex and Julie have much more experience at ground breaking in this area than me.

    Firstly I think it is helpful to distinguish care from caring. Care has come to be associated with the care industry and is often used to describe a set of tasks and physical needs. Care is something delivered by social policy and organisations. Caring on the other hand is a broad concept and one that still has a wider meaning and resonance. Caring is instinctive, emotional, human and compassionate. It is something we all do and all need. Interestingly reading recent reports from Winterbourne View and Staffordshire NHS, poor quality care (badly or cruelly performed tasks) is well described but caring (love and engagement) is largely neglected.

    It is possible to have care without caring but I find it difficult to imagine caring without some measure of structured support from care. In thinking and planning for the future we need care systems and policies that are sustainable and have democratic support but we should not neglect the thought and political leadership needed to create, support and expand caring. Since the war, as a society we have been advancing care in response to demographic, social and economic change but have lost sight of the impact of services and support on the totality of caring available in communities and families.

    I have to say that I don’t have answer to where the proper balance between caring and care should lie but it feels to me that future care policy should seek to increase the level of caring within our society as well as provide reliable, sensitive and accessible care.

    Secondly care is often based on a deficit model – the subject of care needs remedial help to cope with everyday life – and this deficit model extends beyond the physical to the whole person being cared for. With the exception of the personalisation work of Julie, Alex and others, we tend to assume that these deficits are insurmountable and deepen over time. This is particularly true of older people whose care is based on the assumption that declining physical and mental abilities are inevitable and, furthermore, that these will diminish the capacity of older people to contribute to other areas of social, economic and political life. Care becomes the vehicle by which people are gradually removed from valued roles, valued public spaces and from rich social networks.

    Your useful contrast between society’s approach to child and adult care also, in this context, highlights the distinction between our approach to growth, development and enablement of children and our containment, restriction and isolation of older people. Can we not take a pedagogical approach to the care of older people, expanding and supporting their participation and engagement in society? Perhaps we could also expand your earlier ideas on the care experience (which I support) for younger people with an intergenerational approach in which older people and adults also contribute, teach and learn?

    Thirdly we need to think about care as a generic issue that affects us all not something boxed off from our own lives and separate from politics, economics or social reform. One of the frustrating things about care is that many commentators and industry specialists talk as if care is another planet – except, that is, when they run into the care system through the experience of caring for an elderly relative. I think it is useful instead to use a more inclusive approach to care policy and thinking because the realities of aging and care affect us all personally and because it is no more a question for individuals and families in the care system than, say, education is only of relevance to children. “Caring for all our futures” a phrase borrowed and adapted from Scotland’s approach, is not only a sound way of conceptualising the issue but also tactically a way of widening and deepening the debate with the aim of arriving at a new vision and a new settlement in which we all have a stake.

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