7: The limits of social care reform

This chapter looks at the challenges of social care reform and why the four nations have not been able to achieve more change over the period despite the clear commitment across a series of policy documents to do so. It considers an incremental versus transformative approach to care reform, and highlights how both of these approaches must still resolve the challenges of implementation. It explores the ‘policy mix’, highlighting tensions between different policies that make it hard to achieve all of them at once, even if implementation challenges could be avoided. The chapter sets out two paradigms of care policy – the standardised, centralised and formal versus the differentiated, local and informal – and suggests that policy makers must engage with the tensions between these rather than offering ‘the best of both worlds’. The failure to acknowledge these rival paradigms is part of the reason why care reforms to date have faltered, and will continue to be an issue as new sets of care reforms are tabled for the future.

The previous chapter on scale, style and scope highlighted the extent to which the institutional context of the four nations shapes their approach to policy and their relationship with other institutions such as local government. This relates to structure but also to discursive patterns in framing and identity. Scotland and Wales have had a less complex, more consensual and inclusive policy-making style compared to England and Northern Ireland. This has included a focus on trust and co-production over competition and adversarialism, which is relevant to the process of policy-making but also to the types of policies that have been favoured. In this chapter we look at the challenges of social care reform, and why the four nations have not been able to achieve more change over the period despite the clear commitment across a series of policy documents to do so. We consider the patterns of divergence and convergence in relation to social care policy. We compare an incremental versus transformative approach to care reform, and highlight how both of these approaches must still resolve the challenges of implementation. We also explore the ‘policy mix’, highlighting tensions between different policies that make it hard to achieve all of them at once, even if implementation challenges could be avoided. We set out two paradigms of care policy – the standardised, centralised and formal versus the differentiated, local and informal – and suggest that policy makers must engage with the tensions between these rather than offering ‘the best of both worlds’.

Divergence and convergence

Earlier chapters of this book highlighted the high degree of convergence between the four nations in relation to discursive framings of care (the key values underpinning it: wellbeing, fairness, rights, quality and sustainability) and aspirations about the decisions and practices that were required to reform it (redistribute costs of care; personalise support; support unpaid carers; invest in prevention; integrate with health; and professionalise the workforce). In achieving these policy reforms, the scale, style and scope of policy in Scotland has facilitated greater legislative activity than elsewhere. In Wales, devolution has been a more gradual process than in Scotland, and much time and policy capacity has been spent on institution building. Since 1998, the Welsh Government has been reviewing and renewing its constitutional settlement almost constantly, bringing it closer to the Scottish model over time. Primary legislative and tax-raising powers remain relatively new. The link to England and keeping in sync with its care reforms has been felt more strongly in Wales than in Scotland (Boyce, 2017). In Northern Ireland, the periodic and lengthy suspensions of the Executive have been a serious barrier to reform, although the integration with health has facilitated ongoing increases in care spending. In England, the prevalence of veto players, the partisan polarisation on reform proposals, a decade of austerity and the distractions of Brexit since 2016 have meant that care funding proposals have repeatedly been abandoned or delayed (Needham and Hall, 2022).

Despite this varying degree of activity on care policy reform, there is more convergence on results and outcomes across the four nations than might be expected. While formal outcomes measures do not exist across the four nations, we can see that none of them has fully reformed its care system, and (as Chapter 5 sets out) progress on outcomes is fairly similar. We have characterised Scotland as the most ‘active’ of the four nations, but, as Pearson et al (2018) observe, this may have contributed to policy overload that has hampered implementation. Uncertain outcomes and complexity remain key elements of care policy in all four nations. Scotland’s free personal care has concentrated resources on a narrow and functional set of tasks. Improved rights for carers in Scotland, Wales and England have been symbolically important but have been inadequately implemented. Personalisation and self-directed support have lost momentum. Integration continues to have a disappointing record in relation to improving the experiences of people using services. Registration of the workforce in Scotland, Wales and Northern Ireland (along with improved pay in Scotland) has been broadly welcomed. However, workforce shortages remain severe in all four nations, intensified by COVID-19, and we remain some way off social care being a profession on a par with nursing. Prevention has been an important rhetorical commitment in all four nations, but evidence of investment in prevention and discernible benefits for people or communities remains scant.

In explaining why the aspirations of policy makers have yet to be translated into effective system change, we suggest that there is a need to be alert to the dynamics of change in the four nations. In the next section we look at the distinction between more radical and more incremental versions of change, and how these interact with implementation challenges. We then go on to focus on the interrelationships between the reforms (the policy mix), looking at the ways in which they draw on contending care paradigms, which makes reform inherently unstable.

Incremental versus transformative change

All six of the mechanisms set out in earlier chapters for reforming care (redistribute costs of care; personalise support; support unpaid carers; invest in prevention; integrate with health; and professionalise the workforce) are ambitious, wide-ranging and interrelated. Calls for a reformed care system are often framed as a ‘new Beveridge’, evoking the spirit of William Beveridge whose report was the foundation for welfare reform after the Second World War (see, for example, Demos, 2009; Glasby et al, 2011). New Labour’s 2010 Building the National Care Service White Paper set out its agenda in terms that explicitly evoked the spirit of 1948:

Our answer is bold, ambitious reform to create a system rooted firmly in the proudest traditions of our National Health Service. Its creation in 1948 wasn’t just one of Britain’s proudest moments; it was also a profound statement of what can be achieved through collective will in the face of adversity. (HM Government, 2010: 2)

The language of a National Care Service is an explicit attempt to mirror the language of the NHS. It suggests correcting the error of 1948 in which support for those who were ‘dependent’ was fragmented and means tested under the National Assistance Act, rather than universal and free at the point of use as in the NHS. The concept of a National Care Service was used by the New Labour government in 2010 (and has been revived by Labour in subsequent UK elections) and is also deployed in Scotland’s current reforms (Feeley, 2021; Scottish Government, 2021). Plans are being developed for a National Care Service in Wales too, as part of the Co-operation agreement between Welsh Labour and Plaid Cymru (Welsh Government, 2021a).

Attempts to create a system-wide change analogous to the creation of the NHS take a transformative rather than incremental approach to social care reform. This is in line with the critique of ‘piecemeal reform’ offered by the Law Commission in its review of social care legislation in 2011:

It is now well over 60 years since the passing of the National Assistance Act 1948 which remains to this day the bedrock of adult social care. Since then, adult social care law has been the subject of countless piecemeal reforms including new Acts of Parliament and a constant stream of regulations, circulars, directions, approvals and guidance. … Adult social care law, including how it relates to other legislation, has been described at various times by judges as ‘piecemeal … numerous’, ‘exceptionally tortuous’, [and] ‘labyrinthine’. (The Law Commission, 2011: 1)

The Law Commission proposed instead ‘a clear, modern and effective legal framework for the provision of adult social care’ (2011: 2), which was the basis for the Care Act (2014) in England and the Social Services and Well-being (Wales) Act 2014.

Reforming social care through a ‘big bang’ – as the English and Welsh legislation attempted to do – offers a way to avoid the incoherence of a piecemeal and incoherent approach. It may also make it easier to build public and political support around a unified commitment to social care, evoking the post-war Beveridge spirit (Glasby et al, 2011). Reform of long-term care in non-UK systems has often been through a new ‘national debate’ about changing levels of need and entitlement. In Japan, for example, Peng (2016: 281) writes about how, to build public support for reform of older people’s care, ‘the government framed the country’s demographic shifts as a national crisis, and communicated social care as a solution to the crisis.’ In Australia, the National Disability Insurance Scheme (NDIS) for working-age disabled people followed on from a broad-based campaign – Every Australian Counts – that harnessed public and political support for reform (Needham and Dickinson, 2018).

There has been no equivalent ‘national debate’ in the UK on social care, and in the absence of that, we could argue that the ‘big bang’ approach is a poor tactic – maximising the target for veto players and leading to fatalism and ‘review fatigue’ (Bengoa, 2016) when implementation doesn’t follow. Insistence on a ‘once and for all’ solution to care funding, as promised by Boris Johnson when he took office (Campbell, 2019), for example, may have contributed to the failure to make progress on care reform to date. In the old joke about how to eat an elephant, the answer (‘one bite at a time’) has resonance in social care. In a letter to The Guardian, critics noted: ‘The search for the holy grail should be called off in favour of pragmatic reforms that would be feasible and fundable quickly, and would use the initiative of dedicated staff’ (Bosanquet and Haldenby, 2020).

One of the interviewees, a civil servant from England, made a similar point about the effectiveness of incrementalism as a tactic, in relation to how the Treasury plans spending through annual Spending Reviews:

‘We need to take the first steps; the thing to do is to embark on this journey. ... To try and say that … the whole of reform, achieving the whole vision needs to be done in one SR [Spending Review] type period, is just asking for nothing to ever happen. I think to stretch it out across two or three SRs, and start on the journey is really good, for just beginning.’

New Labour suggested a staged approach in its 2010 proposals for reforming care funding. Its White Paper noted: ‘To manage the impact on the public finances, and to ensure that it is affordable and sustainable, we need to build the National Care Service in stages’ (DH, 2010: 8). The first phase was to be free personal care at home, followed by free care for anyone receiving more than two years of residential care. The Barker Report (2014) also suggested a staged approach, starting with free provision of support to people with critical care needs. While such changes lack the symbolic ‘big bang’ of a new Beveridge, they may be more tactically astute in spreading out the challenges and costs of implementation.

There is an extensive institutionalist literature on policy reform and the inertia that makes policy change difficult (for an overview, see Béland and Powell, 2016). Hacker (2004) points out that we need to recognise intermediate points in between no change and full reform. When change occurs it is often through incremental ‘layering’ or ‘conversion’ rather than full-scale reform. If the policy is mutable, then (drawing on the work of Thelen, 2003), Hacker (2004) suggests that we see conversion (in which policies are adapted over time rather than replaced or eliminated). If the institutional context allows new policies to emerge (but there are institutional barriers to changing older ones) we see layering (building on Schickler, 2001). If the policy doesn’t change, despite declining effectiveness in achieving its goals, we can see a case of drift (Hacker, 2004; Béland et al, 2016; Needham and Hall, 2022).

We can see these elements of gradual change in the social care reforms of the four nations. Scotland has taken a layering approach, adding new social care legislation over time while continuing to work within the financial settlement determined by the UK government. In Northern Ireland we can see evidence of conversion – integration with health has given an ‘automaticity’ (Hacker, 2004) to care funding uplifts, which is not the case in the other nations, although formal legislative change has proved impossible. In Wales and England, their respective Acts in 2014 proposed full reform: ‘the removal of existing rules and the introduction of new ones’ (Mahoney and Thelen, 2010: 15). However, the ambition of the legislation has been not been achieved in either nation, with austerity and broader implementation challenges scaling back the planned reforms (Burn and Needham, 2021; Cheshire-Allen and Calder, 2022). In England in particular, the explicit abandonment of the funding cap element of the Care Act has led to drift as the means test has become more punitive over time (Watt and Varrow, 2018; Needham and Hall, 2022). In Wales, we can see layering: there has been some change – for example, in the residential means test threshold and weekly charge for home care. However, implementation of the elements of the Social Services and Well-being (Wales) Act relating to carers has been limited (Cooke et al, 2019; Cheshire-Allen and Calder, 2022).

Implementation problems are well known in public policy, as legislative aspirations interact with the complexity of organisational settings (Pressman and Wildavsky, 1973; Lipsky, 1980; Hupe and Hill, 2016). However, Béland et al (2016) argue that implementation has not been sufficiently explored in the policy change literature. They note how the passage of the Affordable Care Act in 2010 in the USA (following years of drift) was not in itself the marker of policy reform, as it has continued to be subject to amendment and reversal during its implementation in the states. In line with this, Carey et al (2019) argue that we need to pay more attention to the ‘sticky layers’ that inhibit implementation of policy reforms. The introduction of Australia’s NDIS – the focus of Carey’s study – offered a ‘big bang’ type of reform, with ambitious plans for the scale and timing of implementation. However, Carey et al (2019) found that even transformative changes have to deal with institutional stickiness as new initiatives are layered on top of existing systems and markets. In relation to social care, we have to be aware of the extent to which both gradual and more transformative reforms have had to address factors such as limited public funding, existing labour markets, the mixed economy of provision, and variable willingness and capacity in local government to introduce reform.

Policy makers themselves are aware of the challenges of implementation. The Care Act 2014 was accompanied by a designated Implementation Support Programme and a new regional infrastructure to support local transition (Hudson et al, 2019). Nonetheless, the implementation of the legislation has been disappointing, with ambiguity in the legislation itself intersecting with financial pressures on local authorities to inhibit change (Burn and Needham, 2021). These challenges of policy reform are part of the explanation of why, despite 25 years of reform, social care in England, Scotland, Wales and Northern Ireland remains unfinished business.

The policy mix

The implementation barriers facing large-scale system changes are an important part of understanding why care reform has been delayed or reversed in the four UK nations. There is a related element that needs to be considered in order to understand the challenges facing care reformers. This concerns the internal tensions between the reforms, and the failure of policy makers to articulate and resolve these tensions. Carey et al (2019: 494) draw attention to the ‘policy mix’ and the importance of ensuring that goals are coherent in the sense that they are ‘related to the same overall policy aims and objectives and may be achieved simultaneously without requiring trade-offs, temporal sequencing, or value balancing’. They go on: ‘This makes the composition of policy change important: these relations between different parts of policy over time are not simple additive ones; rather they are dynamic and complex, and typically have emergent, self-organizing properties’ (Carey et al, 2019: 494).

The importance of understanding the relationships between parts of the ‘policy mix’ has been the focus of a number of studies (see, for example, Howlett and Rayner, 2007; Flanagan et al, 2011; Béland et al, 2020; Sewerin, 2020). Howlett and Rayner (2007) note that a policy mix often evolves over time: policies may be incoherent or counter-productive, leading to suboptimal outcomes. In considering the policy mix in social care reforms, we can explore how the six mechanisms (redistribute costs of care; personalise support; support unpaid carers; invest in prevention; integrate with health; and professionalise the workforce) come together as a policy mix. In particular, we draw attention to the rival paradigms at work here. Some of these reforms (particularly integration with health and professionalising the workforce) seek to promote more standardisation, centralisation and formality within the care system whereas others (particularly personalising provision and investing in prevention) encourage more differentiation, localism and informality.

Standardised versus differentiated approaches to social care

In 2021, Professor Nick Watson from the University of Glasgow gave evidence to the Scottish Parliament about the Feeley proposals for a National Care Service, saying:

[O]ne problem that I see from reading the report … is that it seems to present two different futures for social care. On the one hand, it suggests that good social care is the product of people power, the co-production of services and a diversity of approaches that are adapted to meet the needs of the locality and the needs of each service user. On the other hand, it calls for centralisation and standardisation, and institutional power, through a national care service. Those two approaches seem to be in tension with each other and, as I read through the report, I really struggled to see how they could be reconciled. (Scottish Parliament Health, Social Care and Sport Committee, 2021)

Watson’s articulation of these two approaches – implicit and in tension – coheres with our analysis of two strands underpinning reform in the four nations since devolution. Across the policy documents all four indicate a clear commitment to self-direction and personalisation and to prevention, co-production and asset-based approaches to individuals and communities. Yet, there is also a centralising and standardising dynamic in all four nations, evident in the approach to regulation and registration and to structural integration with health.

One of the interviewees, reflecting on how the Social Services and Well-being (Wales) Act 2014 is working in practice, pointed to the tension between loosening and maintaining control:

‘We’re almost in a bit of a dichotomy aren’t we? The Social Services and Well-being Act is all about power to the individual person. So, have a direct payment, commission your own, employ your own, do what you want with that money. We’ve assessed your need, within limits, obviously, but you go ahead and you look after yourself. The counter argument is, regulation, regulation, we’ve got to keep everybody safe.’ (Wales, social worker)

We see these as two paradigms that underpin reform initiatives in all of the four nations, but with insufficient attention to the tensions between them. They can be set out as ideal types in order to highlight the differences between them, and the problems that follow when reformers leave the tensions unacknowledged.

Paradigm 1: standardised care

This first paradigm is associated with strong state control of care, and with the provision of nationally standardised and regulated systems. Of our six mechanisms of care reform, this paradigm gives most attention to macro-level funding reform, integration and worker registration. It is least likely to prioritise self-directed support and prevention. A key characteristic of this paradigm is its emphasis on a professionalised and regulated workforce. This derives in part from concerns about safety. As this interviewee put it, raising concerns about unregistered care workers: “You wouldn’t expect an electrician to come and do your house who wasn’t qualified, yet we’re saying it’s okay for somebody to go in who is not qualified to do the most intimate things with individuals who are very vulnerable, not supervised, on their own” (Wales, regulatory/oversight body).

The rationale for the registration of care workers comes in part from a sense that policy has lagged behind the changes in care work, which now make it closer to nursing than to a ‘home help’, as discussed in Chapter 3. Given the focus on formalisation, this paradigm is also allied to the integration agenda, with the creation of the NHS seen as the model social care should move towards, as exemplified here by an Assembly Member from Wales:

‘We have a mish-mash of public provision. Well-meaning charitable provision. Private provision. Somebody needs to have the courage to bring it all together into a standalone coherent service. Like Aneurin Bevan did for health. Somebody needs to do it for social care. And that’s the challenge at the moment, because people say, “It’s too difficult, it’s going to be horrendously expensive”. But that was all the arguments hurled at Aneurin Bevan, back in the day, which is why I am quite a fan, really.’

One rationale for staff registration is to make it easier for staff to move between social care and the NHS:

‘Well, I’m a supporter of registration, but only if it’s a properly backed system. ... The aim of registration should be about a proper skills and competency framework. It would be aligned to the NHS one, because we want staff who can move seamlessly between systems, just as citizens do.’ (England, provider representative)

Personal assistants (PAs), who are not required to be registered in any part of the UK, can be seen as anomalous and problematic in this paradigm: “You think about personal assistants, are they not regulated because they’re not dangerous? Because there’s no risk there? I don’t think that’s the case. It’s the ‘too hard’ pile, isn’t it?” (England, regulatory/oversight body).

Some also see non-registered providers, such as PAs and micro-providers, as creating unfairness in the system, because they can work unregistered, while other providers must register their staff:

‘From our point of view, if we, as a group of contracted, commissioned, service providers are legally obliged to register people, to have them qualified – for all the reasons that have been given – then what on earth is the justification for having a whole bunch of people who call themselves micro-providers, to exist entirely outside the regulatory framework? Who don’t have to be scrutinised in any way at all. Who don’t have to comply with any of these things, and furthermore who are outside the living wage policy of the Scottish Government.’ (Scotland, third sector)

In Scotland, the proposed National Care Service, as set out in the Scottish Government’s consultation document in 2021, is most closely aligned to the paradigm of standardised care. The problems of the care system are set out as being insufficient consistency and standardisation (Scottish Government, 2021). The language of personalisation and co-production is there, but the mechanisms of change – particularly a new national approach to commissioning – are standardising reforms. The Coalition of Care Providers Scotland (CCPS), representing 80 not-for-profit providers, expressed dismay that the consultation focused on structural change, not culture: ‘As they are currently articulated, the changes proposed by the Scottish Government appear to rely on two key drivers – more control from the centre and greater enforcement of standards. However, the emphasis on structures and practices is not matched by an equally explicit focus on culture, relationships, and behaviours’ (CCPS, 2021: 3).

Long-stay care institutions are part of this standardisation paradigm. This includes the ‘Assessment and Treatment Centres’ for people with learning disabilities, which have proved very difficult to close, despite media and political pressures to do so. Research on ‘carceration’ (Series, 2022) and ‘new asylums’ (Fox, 2018) finds that institutional models have been recreated or preserved, despite the elimination of long-stay hospitals. The COVID-19 pandemic highlighted that institutional settings can be high-risk environments (Knapp et al, 2021), and many relatives were distressed at the extent to which residential care settings remained closed institutions, even as broader COVID-19 restrictions eased (Tapper, 2021). Writing about ‘the invisible asylum’, Fox argues that even outside of formal institutions, norms of control can be present within social care in which notions of home, family and love have no currency: ‘Most of the most obviously institutional buildings have gone, but the ideas behind that divide between those inside and those outside the community remain invisibly woven into our public services which provide long-term support’ (Fox, 2018: 14).

The efficiency arguments around building large care institutions mean that they continue to be a part of care provision, despite quality concerns expressed by the English regulator (CQC, 2017). This efficiency logic is evident in claims from this interviewee that meeting future care needs is likely to require institutional solutions unless other ideas are forthcoming:

‘You’re not going to get good care and good carers to meet the ageing population across the UK, and particularly across parts of Northern Ireland. We’re going to require them all to move to where we build big massive care homes. Or what arrangements are we going to put in place? And there is part of me that doesn’t understand why that’s too hard to plan for.’ (Northern Ireland, regulatory/oversight body)

One interviewee, a social worker in Northern Ireland, felt that COVID-19 may have increased the tendency to favour large institutions:

‘What we might do is actually take our large, big group care institutions and say, “Well, we have really high demographics, and actually these facilities are really good at discharging people from hospital quickly”. And if we shore them up with better clinical care, they can feel a bit more like hospitals. We’ll reduce the risks to people living in them, in terms of infection, and we’ll reduce our risks as people running the system. We’ll feel a bit happier that they feel a bit more like what we do in hospitals.’

There is a sense from these two interviewees that the crisis of demand and the pandemic experience may have strengthened the appetite for institutional care at scale.

Of the four types of supply discussed in Chapter 3 (state, market, family and community), the standardised paradigm is most closely connected to the legitimacy of the state. Restoring the state’s role in designing, funding, commissioning, regulating, registering and potentially delivering care is a key priority. There may be roles for other points of the care diamond – the market, family and community – but in this paradigm each of these is considered too partial and unreliable to be trusted to provide consistent, high-quality care.

Paradigm 2: differentiated care

This paradigm starts with the person receiving support and what enhances their wellbeing. This might be a regulated care service, a non-regulated PA, or a range of family and community supports. Rather than keeping people safe through national standards there is more emphasis on local variance, co-design and co-delivery and involving people in informal networks. Safety is traded off with other goals through the lens of positive risk-taking rather than risk aversion (SCIE, 2010).

A commitment to this differentiated paradigm runs through many of the policy documents we analysed. It can be seen across the four nations – in Putting people first (HM Government), in England’s Care Act 2014 and in the Social Services and Well-being (Wales) Act 2014, in Scotland’s Feeley Report (2021) and in Northern Ireland’s Power to people (Kelly and Kennedy, 2017). Support for this kind of approach comes in part from an awareness of the limits of what has been achieved through the standardised approaches of the first paradigm. This interviewee, for example, expressed reservations about relying on regulation to keep people safe:

‘Like the rest of the UK, we’ve faced some fairly catastrophic failings in quality of provision. We’ve got some major adult safeguarding investigations going on, relating to managed care environments where the quality of the care certainly was neglectful and is sometimes abusive. I really don’t think that we’ve cracked that, I also don’t think inspection will crack it. ... I think there has to be something about how we commission that care that makes it inherently safer, rather than relying on inspection and regulators to catch it being unsafe. … If you look at the failures of quality in provision, it’s fairly classic, the two things that they require. If it’s abuse, it is basically an unequal power relationship and if it’s abuse and/or neglect, it’s secretive and covered up. Now, the two tenets of co-produced services are that you share power, and that they’re totally transparent. I just think that people haven’t connected co-production with avoiding those kinds of quality failures yet. But that’s where you’ll get to. I think that care that is co-produced, and care that has resulted from diffuse power and is transparent in its nature, it’s just inherently safer.’ (Northern Ireland, civil servant)

In the Feeley Report, the limits of inspection and regulation in assuring quality are acknowledged:

[W]holesale reliance on inspection is seldom appropriate, and is costly in both time and money. And most important, inspection cannot always catch problems that are inherent in the system itself. And yet, that is pretty much all we have in social care support a total reliance on external verification as a vehicle for improvement. It won’t work. It distorts our sense of who is the ‘customer’ away from the person in need of care and support towards the inspector and it inhibits the sharing of learning and innovation. (Feeley, 2021: 58)

A local Welsh interviewee, a care commissioner, felt recent legislation had emphasised personalisation and flexibility, but that this was being lost in implementation:

‘I think the Regulation and Inspection Act, 2016 has kind of missed the point with a couple of aspects. ... They start off really well, and in the main it’s in line with the spirit of helping people live their lives like they want to live them, have good outcomes. But sometimes there’s still that kind of aspect of ... micro-managing the providers creeping back in. And it’s the same with the Social Services and Well-being Act. The values, the principles, are fantastic – but then once you delve into some aspects of the guidance, and some of the sections around the Act, you see, hmm, there’s a little bit of tension here, between what you’re saying as an overall vision you want to achieve, and what we have to do.’

An interviewee in Scotland, a civil servant, set out the limitations of the current model:

‘We’ve trained [care workers] to be person-centred, and generally people going into those professions are genuinely wanting to do a good job. But actually ... we’re training them to fill in the contractual obligations. So, you go in, and actually your top marks are to fill in that book to say “Joe’s mood is low and we’ve given him his medication”. Then, you’ve got five minutes to nuke the meal, but you’ve got another five minutes to write up what the meal was, and whether Joe ate it. But you’re not sure if he ate it, because you’ve got to go next to Jessie. ... That’s not good support. That’s not good for the worker, for the person who’s receiving it.’

The second paradigm – of differentiated support – aims to move care beyond a set of work tasks (Rummery and Fine, 2012). In relation to the care ‘supply’ crisis discussed in Chapter 3, this paradigm evokes family and community as having the most to offer. The state and the market are distrusted as too instrumental – treating care as a set of functional tasks. Families and communities, while they can be under immense strain, are seen as the most likely to offer love and reciprocity (Fox, 2018), as well as kindness (Unwin, 2018). This is evident in Northern Ireland’s Power to people report, which states that ‘Care and support involves supporting a human environment and culture that encourages relationships and kindness’ (Kelly and Kennedy, 2017: 64).

Comparing the two paradigms

Having a preference for a standardised versus a differentiated paradigm has implications for the perspective taken on the social care values set out in Chapter 2. The first paradigm is suggestive of a care system that is highly formalised, standardised and regulated, with registration for care workers and a clear demarcation between what it means to be ‘in’ or ‘out’ of social care. It gives pre-eminence to making social care work for other systems connected to it – particularly the NHS. Attention is given to how to make the work of care more effective and efficient, foregrounding the perspectives of paid care workers. Policies include reasonable rates of pay and training for care workers, with good terms and conditions, and legislating for unpaid carers to have rights to support, including respite. Safeguarding is also important, as is regulating care systems so that care meets a quality standard and keeps people safe. The main problem that this paradigm seeks to tackle is a lack of consistency and inadequate protection for those who provide and receive care.

The second paradigm sets out a vision of care and support that is differentiated and less formal, with lower levels of regulation and greater variation between localities and between people. Social care here is not something you go ‘into’, in the way you might go into hospital; it is something that gives you support so that you can do the things that enhance your wellbeing (#socialcarefuture, 2019). Care here is approached through the perspective of the person who requires support and the focus is on what will give them choice and control so that they can flourish. Their preferences will be paramount, and formal systems will exist to facilitate these, while allowing maximum flexibility. So, for example, people may be able to choose a care worker from a regulated agency or use a non-registered PA. People can spend a direct payment on buying a traditional ‘care package’ or on a range of things that they feel will support their wellbeing.

We present our typology of the two paradigms in Table 7.1.

Table 7.1:

Two paradigms of social care

Features Paradigm 1: standardised care Paradigm 2: differentiated care
Core values • Consistency

• Safety
• Choice and control

• Strength-/asset-based approaches
Exemplar funding reform • Free personal care • Direct payments
Exemplar mechanisms • Integrate with health

• Professionalise the workforce
• Personalise provision

• Invest in prevention
Perception of wellbeing • Wellbeing is a service outcome from efficient delivery of quality services to people with support needs • Wellbeing emerges from a good life; social care facilitates people’s pursuit of what matters to them
Rights • Service users and service providers require clearly defined and enforceable rights and duties, to ensure safety and consistency • Individual rights should be matched with recognition that people and communities have assets, and care is a mutual relationship
Quality • Clear, enforceable quality standards

• Powerful regulatory and inspection system
• Is negotiated between stakeholders

• Emerges from good relationships

• Requires positive risk-taking
System sustainability • Achieved via a well-funded state that distributes services equitably to achieve well-defined outcomes • Achieved by embedding people within caring communities supported by the state and the market
Key concerns • Unsafe care

• Inconsistent care across localities

• Poor terms and conditions for staff
• Institutionalisation

• Lack of personalisation and co-production

• Lack of innovation

• Stigmatisation

Within the standardised paradigm, we can see the core values as being safety and consistency. A care system is effective if it is able to secure consistent care for all (as part of fairness) and ensure people are kept safe. The key reform mechanisms relate to integration with health (to improve service outcomes) and professionalisation of the workforce as the basis for safe and consistent care as well as making care work more consistent with other caring professions. Free personal care is an exemplar policy, in which everyone with an assessed need can have support in achieving an agreed list of Activities of Daily Living. In the differentiated paradigm, the focus is on prioritising choice and control for the individual, using direct payments as much as possible to enable people to purchase the services that they feel help support their preferred outcomes. Prevention is a key mechanism here, alongside personalisation and self-directed support, and recognition that people have strengths and assets rather than only ‘needs’.

In relation to wellbeing, we can differentiate between wellbeing as something that the care system provides (in the standardised paradigm) and wellbeing as a broader life perspective (in the differentiated paradigm). Crowther captures that broader sense of wellbeing:

A comment bubble comprises a tweet by Twitter-user Neil Crowther.
Figure 7.1:

Neil Crowther tweet on wellbeing

Source: Neil Crowther, Twitter, 28 October 2021
In the standardised paradigm, rights are a key focus for reformers, ensuring that people have protected rights to services and funding. In the differentiated paradigm, recognition of the difficulty of enforcing rights and duties means more attention is given to relationship building, trust and attributes such as kindness (Unwin, 2018). Quality in the standardised paradigm is about the match between the commissioned service and the service delivered, whereas in the differentiated paradigm, quality is defined by the people using the service. Two quotes from the interviews indicate this contrast. The first problematises the perspective of the person receiving care in not recognising the limits of what is being provided:

‘I think it’s very difficult, because what you hear at a personal level, and the personal experience, there’s such a tension in that. There’s nothing good about the care you’re getting. “I know you think Edna’s lovely, but there’s nothing good about the care she’s actually being paid to deliver”.’ (Northern Ireland, third sector)

In the second, the interviewee highlights the importance of what family carers value, which may not be covered by a service specification:

‘My dad did agree to have the hairdresser come around to do mum’s hair. Actually, she wasn’t very good at hairdressing, but what he did, he paid her for an extra hour to do a bit of cleaning. She was a rubbish cleaner as well, not brilliant at hair or cleaning, but what she did was sat and talked to mum, so dad could go out into the garden and potter.’ (England, third sector)

In the standardised paradigm in which services meet a specification, there is a clear failing here. In the differentiated paradigm, there is recognition that quality is developed in the relationships and can be defined by the people receiving support. This is not always straightforward, of course, and perhaps in this example, a good cleaner and a good hairdresser would have been more helpful. The point at issue is: who decides?

Key concerns for the two paradigms highlight the values and mechanisms that each prefer. The standardised paradigm gives priority to preventing exploitation of staff, unsafe care and inconsistency of provision. The differentiated paradigm has a different set of worries: deficit models that lead to institutionalisation of one kind or another, and to stigmatisation, service standards that are focused on functional tasks without scope for personalisation or innovation around what makes a good life. All of these are legitimate concerns: however, the two paradigms differ in what gets foregrounded in policy-making and implementation.

Universalism versus particularism

We present the two paradigms as ideal types rather than system descriptors. Nonetheless we argue that they do inform the ‘policy cores’ (Sabatier and Weible, 2019) or ‘philosophies’ (Schmidt, 2008) that sit behind specific policies and programmes. These paradigms align to a degree with the broader accounts of universalism versus particularism that underpin any welfare state (Taylor-Gooby, 1994; Thompson and Hoggett, 1996; Hoggett, 2006). In a care context they have been played out in the historical development of state care services that drew legitimacy from a narrative of universalism (or what we have called standardisation) in contrast to the particularism of market, family and community (Ouchi, 1980; Bartels, 2013). As the critique of institutionalisation gathered pace in the 1980s, the state was recognised to be just as particularistic in its treatment of people and its insensitivity to social diversity (Williams, 1989). Rather than a dysfunction to be designed out, some versions of particularism offered a way to move beyond the Fabian welfare model and provide more tailored forms for support (Thompson and Hoggett, 1996). Relational models of support came to be seen as essential to effective models of service delivery rather than a threat to bureaucratic impartiality (Bartels and Turnbull, 2020). People were understood to be co-producers and co-commissioners of their care (Needham and Carr, 2009), and communities to be a source of assets and wellbeing (#socialcarefuture, 2019).

In relation to social care, our two paradigms offer specific manifestations of these broader tensions within the welfare state. We distinguish between paradigms that seek to assure access to a standardised and regulated set of services versus those that seek to facilitate person-centred, relational forms of support, which may involve formal services but may also improve access to a range of informal activities. Hoggett argues that the tensions between universalism and particularism cannot be resolved, but they do generate ‘value contradictions’ for public officials (2006: 178). We suggest that it is these value contradictions that help to explain the lack of progress on many care issues that are being pursued simultaneously, particularly integration (universalism) and self-directed support (particularism), or free personal care (universalism) and prevention (particularism). Integration has often focused on how social care can help the NHS (for example, quicker hospital discharge packages) rather than on how people can have more choice and control. Free personal care has focused resources on a relatively narrow set of functional supports in the home, drawing attention and resources away from investing in the local assets and networks that keep people out of the formal care system.

By making explicit the two paradigms that run through care reform it is clear that care can contribute to narrow or broad understandings of wellbeing. In the differentiated paradigm, there is recognition that wellbeing cannot be delivered by services. Separating out these two paradigms has the advantage of helping to explain why systems that emphasise the importance of (say) integration with health appear to lose focus on personalisation or self-directed support (Pearson et al, 2018). It highlights the limits of claims that sustainability in social care is only about putting in more money, such as through capping care costs (DHSC, 2021d).

We can argue that the differentiated paradigm is the most appealing – with its emphasis on person-centredness and subjective wellbeing. However, it is important to also recognise its limits. This account has little to offer care staff in terms of routes into training, better pay or career progression commensurate with the kinds of work they do. Research on PAs highlights advantages of working in this way, but that there are disadvantages too (see, for example, Shakespeare et al, 2018; Manthorpe et al, 2020). Carers’ right to breaks may be better protected in a system that gives primacy to standardisation and formalisation. The valorisation of love and family in the differentiated paradigm resonates with what many people would want from life, but family-based care is heavily gendered and can be inadequate (Tronto, 2013). It may be that standardised approaches fit certain contexts. For example, integration with health (which we suggest is part of the standardised paradigm) may be an effective way to offer short-term support, but be less suitable for longer term provision. As a former chair of England’s Association of Directors of Adult Social Services, James Bullion, observed:

A comment bubble comprises a tweet by Twitter-user James Bullion.
Figure 7.2:

James Bullion tweet on integration

Source: James Bullion, Twitter, 8 September 2021
Reconciling the two paradigms, and identifying how best to combine elements of them, requires being much more explicit about them. Responding to Watson’s evidence to the Scottish Parliament, Derek Feeley acknowledged:

[Nick Watson] is probably right that there is a tension between standardisation and personalisation. However, we need both of those: we need to enhance both standardisation and personalisation if we are to have the kind of social care support system that we want in Scotland. We are going to have to manage that tension in the best way we can. (Scottish Parliament Health, Social Care and Sport Committee, 2021)

While Feeley may be right that elements of both approaches are needed, many debates about social care feature a tendency either to ignore the tensions or to discredit the alternative. In the final chapter we set out ways to more explicitly debate the value tensions within social care.

Conclusion

This chapter has explored the patterns of convergence and divergence found in the book. It considered the distinction between transformational and incremental reforms, noting the tactical advantages of more incremental change as pursued in Scotland. Scotland’s approach of ‘layering’ has avoided the risks of loading too much into a single transformational piece of legislation – as attempted in England and Wales – which may overwhelm implementing bodies. However, the implementation challenges of change have been a barrier in all four polities, and the dysfunctions of the care system remain such that all four nations are promising further large-scale reform in the future.

In understanding the barriers to policy change we also have to consider the ‘policy mix’—in other words, how the proposed mechanisms of change fit together. In setting out two paradigms of care here, we have highlighted tensions in what care reformers are seeking to achieve. Approaches that seek to make care standardised and consistent, with a more professionalised workforce and a closer integration with health, offer one kind of care future. In contrast, approaches that seek to make care more local, more differentiated, more co-produced and more strengths-based are invoking a very different understanding of what constitutes good care and a good life. Failure to acknowledge these rival paradigms is part of the reason why care reforms have, to date, faltered, and will continue to be an issue as new sets of care reforms are tabled for the future. In developing care policy, the tensions between these two are either ignored altogether or are over-stated, to the extent that no accommodation is possible. In the next chapter we suggest ways in which it might be possible to develop more multi-vocal debates about care.

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