There has long been a gap between what national government says about the need for social care to achieve and evidence outcomes, and the reality of the kind of basic functional support that local government can and will buy. This gap has widened during austerity and is now unbridgeable without significant additional funding for councils to provide adequate social care.
However, this gap in both vision and reality for the social care sector started widening long before austerity. The starting point for the long-running Think Local, Act Personal partnership and its ‘making it real’ project was that not everything labelled ‘personalisation’ felt personal. Without demonstrating that it can bridge that divide, it seems unlikely that the Treasury and No. 10, will invest anything like what is needed for the sector’s survival. And yet on this hinges the survival of the NHS.
As we head to yet another Green Paper, the existential challenge facing the social care sector is to demonstrate that it can offer something which people not only need when they are desperate, but will genuinely value and love, in the way that they love the far-from-perfect NHS.
And academia had a vital role to play in helping to define this offer. But there is no ‘neutral’ position for academics to take on this. Do they look for outcomes which are set out in legislation, but which many services particularly for older people, are not asked or paid for and do not attempt to achieve? To whom do they ascribe blame for the gaps and failures they will surely find: hard pressed, underpaid frontline workers, providers which teeter on the edge of financial viability, local government commissioners who lack the money to buy what people need, or central government which has devolved spending decisions to the local level?
Funding bodies, and the institutions which bid to them, put the majority of their resources into researching the most prevalent models such as care homes and home care. That is pragmatic – those models support over a million people and so offer researchers large sample sizes. They are also the most significant budget lines in council and NHS budgets, so whether they are good value for public money matters. But through corralling the biggest share of research budgets, this ensures that the evidence base for traditional models strengthens, whilst innovative models like Shared Lives, Homeshare, Community Circles, Time Credits or Local Area Coordination are locked into an endless cycle of small scale qualitative research which finds them to be promising but unproven.
This in turn risks entrenching risk-averse procurement on a ‘better the devil you know’ basis: choosing certain kinds of predictable failure over the possibility of success, particularly where ‘success’ would mean outcomes valuable to people but not valued by the broken economics of our health and care system.
Personalisation can be defined as combining service support, as well as the service user’s own capacity and the strengths of family and community to strive for good lives. It remains deeply contested, patchily implemented at best, but nevertheless is the only credible vision on which to base a social care system which could be valued enough by people who need it to make investment in it politically necessary. Personalisation is a whole-system change and part of a deeper culture change, which makes it impossible to research using approaches which look only at specific impacts of specific services.
Interestingly the National Audit Office’s report into the evidence base for personalisation claimed to have found little, but in reality had found that personal budgets, only ever intended to be one part of a shift towards personalisation, lacked evidence. This was unsurprising given their own partial implementation and their reliance for impact upon changes which have not yet happened, such as the development of brokerage and new models of support.
Admittedly, I write this from a non-neutral perspective. As an advocate for Shared Lives and Homeshare, I would argue that Shared Lives has demonstrated how it outperforms all other models of regulated care -according to the CQC. It operates at a lower cost, with disabled and older people consistently describing how they live happier and fuller lives with their chosen Shared Lives carer and feel valued as a family and community member. But development of this scheme is patchy, with some regions far outpacing others.
As regards to academic research in this field there is a lot more to do. Despite recent ground-breaking work by a team at the University of Kent this model of social care has been largely ignored by academic researchers. Yet without research to back up these emerging models of care, potential for widespread development and Government support of these schemes could be limited. So the time is right for bold academic decisions - decisions that are actually choices about whether to observe social care’s decline and perhaps demise, or to contribute to its survival and transformation.
I am delighted to be joining the University as an honorary senior research fellow in the School of Social Policy. The school’s mission is ‘to change the world as well as to understand it’ and I am looking forward to working with academic colleagues to develop effective ways to make that real-world impact.