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  • Author or Editor: Patrick Hall x
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This chapter uses the frame of crisis to explore issues of supply and demand for care in the four nations. It looks at the extent to which demographic changes are increasing the demand for care and support. Using the care diamond framework, it looks at the contributions of the family, state, market and community, and what it means to say that each of these are ‘in crisis’. It considers the extent to which there is a differentiated crisis between the four nations, with important background conditions – such as the extent of self-funding or of market provision – varying between them. The crisis in England is often portrayed as a crisis of public service cuts, exacerbated by COVID-19 and Brexit. The crisis in Scotland and Wales relates more to rising demand. In Northern Ireland, the crisis has partly been one of policy inactivity and political stasis. Responses to these ‘crisis claims’ involve different responses from policy makers in each of the four nations. In Scotland, for example, there is more optimism about the role of the state as in crisis reversal, whereas in England the government expects the market to drive the move from crisis to sustainability.

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This chapter considers whether the UK’s nations have achieved the outcomes that they aimed for. It begins by highlighting the increased focus on outcomes within care policy in all four nations. In goes on to highlight that some of policy reforms are in tension, meaning that it is unlikely that they can all meet their desired outcomes at the same time. While formal outcomes measures do not exist across the four nations, none of them has fully reformed their care systems, and progress on outcomes in the four is fairly similar. Scotland is the most ‘active’ of the four nations, but this may have contributed to policy overload, which has hampered implementation. Uncertain outcomes and complexity remain key elements of care policy in all four nations. In all four, funding reform is incomplete; personalisation and self-direction has stalled, at least in relation to individualised funding; carers’ rights have not been implemented; integration has failed to deliver clear benefits; and registration and improved pay for care workers in some jurisdictions has been welcome, but may have intensified capacity issues and assures neither quality work nor quality care.

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This chapter considers the institutional design and approaches to policy-making in the four nations to explain some of the similarities and differences in their approaches to care. It looks at how the scale, style and scope of policy has made it easier for Scotland to be the most active on care policy reform, making the most of a relatively consensual policy environment, with limited veto players. England has been hampered by its larger and more siloed institutions, influential veto players and an overloaded agenda. Wales and Northern Ireland have had constitutional factors to deal with throughout the period, which have delayed (Wales) or inhibited (Northern Ireland) their capacity to be active policy makers on social care. In Scotland and Wales there has been a discursive rejection of the market and consumerist approaches to care, with a preference for seeking to pursue care reform through community and co-production. In Northern Ireland, the crisis of the state has had a very distinctive hue, and some of the work of reforming social care has been about detoxifying the state. In England, the market continues to be dominant, although a role for community in prevention is recognised.

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This chapter looks at care reforms in the four nations of the UK since devolution. These can be categorised as the following six mechanisms: redistribute the costs of care; personalise support; support unpaid carers; invest in prevention; integrate with health; and professionalise the workforce. These broad goals of reform across the four nations are very similar. All six of the policy reforms have been attempted, although the tactics through which this has been done are different. Scotland is the nation that has made most progress on care policy reform. These approaches can be summarised as, in the case of Scotland ‘active’, in Wales ‘emergent’, in England ‘symbolic’ and in Northern Ireland ‘stalled’.

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To assess and compare the four care systems of the four nations in the UK it is important to have a clear sense of what they are trying to achieve. This chapter focuses on how policy documents in England, Scotland, Wales and Northern Ireland frame social care, and how care policy supports the aim of improving social care. It looks at what policy makers have set out in the documents as being their vision of sustainable care and a good life for people with care needs. Despite the definitional ambiguities and boundary issues, policy documents from the four nations have a similar vision of what social care policy is aiming to achieve. The overarching principle in all four systems is that care policy should maximise individual and collective wellbeing. It will do this by being fair, rights-based and high-quality – and ensuring these goals are achieved for everyone in the system (people who use services, unpaid carers and care workers). These elements combined are expected to deliver sustainability. We look in turn at wellbeing, fairness, rights, quality and sustainability, as well as at the tensions that can arise when all of them are in focus at once.

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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.

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This chapter summarises the findings of the book and considers how policy makers can more productively engage with the tensions between the two care paradigms in order to move towards a more sustainable care system. By making these paradigms explicit, the book exposes key points of difference, and why care reformers often speak past each other because they are focused on different means and ends. The paradigms shape both specific mechanisms for reform as well as broader questions about what sustainability means in a context of care. Drawing out the paradigms enables us to ask questions about wellbeing, fairness, quality, rights and sustainability in care.

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Between Two Paradigms

Two decades have passed since the devolution of social care policy, with key differences emerging between the UK’s four systems, but what impact have these differences had? This book presents for the first time research on the perspectives of social care policy makers on the four systems in which they operate and the ways in which they borrow from one another.

Drawing on extensive interviews with national and local policy makers across the UK, the book raises vital questions about the role of ‘standardisation’ and ‘differentiation’ in social care, concluding that when given equal capacity to reform their respective systems, the regimes in each nation may take radically different shapes.

Chapter 4 and chapter 7 are available Open Access under CC-BY-NC-ND licence.

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This chapter sets out the rationale for comparative social care research in the four nations of the UK, along with key theoretical approaches and research methods. It highlights the extent to which social care in England, Scotland, Wales and Northern Ireland is facing a crisis, further deepened by the COVID-19 pandemic. It defines adult social care and gives an overview of the devolution settlements in the four nations. It sets out the method for the interviews and document analysis that are drawn on in the rest of the book, and summarises the chapters that follow.

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