October 26, 2023 • 29 mins
This episode looks into Catherine’s and Patrick’s recent book entitled "Social Care in the UK's Four Nations: Between Two Paradigms". Focusing on England, Scotland, Wales, and Northern Ireland, the book examines the differences in care systems.
Catherine and Patrick identify five care crises, including demographic changes, family roles, state involvement, market challenges, and community support. We discuss how policymakers in the four nations employ various mechanisms aim to achieve common goals in an effort to solve these current issues.
The episode provides valuable insights into the challenges and goals of social care reform in the UK's four nations, emphasising the need for a comprehensive and sustainable approach.
"Social Care in the UK's Four Nations: Between Two Paradigms" is available to buy here: https://policy.bristoluniversitypress.co.uk/care-in-the-uks-four-nations
Chapters 4, 'The mechanisms of social care reform', and 7, 'The limits of social care reform', are available to read Open Access on Bristol University Press Digital.
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Learn more about our research on the Centre for Care website here: https://centreforcare.ac.uk/
The CARE MATTERS Podcast is produced by Dan Williamson at the Centre for Care.
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The Care Matters podcast is
brought to youby the ESRC Centre for Care and CIRCLE,
the Centre for International Researchon Care, Labour
and Equalities.
In this series,
our researchers welcome expertsin the field and those giving or receiving
care to discuss crucial issuesin social care as we collectively attempt
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to make a positive differenceto how care is experienced
and provided.
Hello
and welcome to this episode of the CareMatters Podcast.
I'm Dan Williamson.
I'm the producer of the podcastand the digital and communications
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coordinatorfor the ESRC Centre for Care and CIRCLE.
For today's episode,
I am pleased to be joinedby two colleagues
whom I've worked withfor a number of years, starting during
the ESRC-funded Sustainable Care program,
which ran from 2017 to 2021,
and they've authored a book detailingresearch and findings
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carried out during the program,entitled ‘Social Care
and the UK's Four NationsBetween Two Paradigms’.
And this is what we've cometogether today to discuss.
Catherine Needham
is professor of Public Policyand Public Management
at the Health Services Management Centreat the University of Birmingham.
Her research focuses on social care,including personal isolation,
(01:36):
co-production, personal budgetsand care markets.
She's published a wide range of articles,chapters
and books for academic and practitioneraudiences.
Katherine led the care in the Four Nations
work package within the ESRCSustainable Care Team.
She's now leading research on care systemsas part of the ESRC Centre for Care
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and is also a member of IMPACT,The UK Centre
for Evidence Implementationin Adult Social Care.
Welcome, Catherine.
Thanks, Dan And we also have with us todayPatrick Hall.
Patrick is a social care policy researchercurrently undertaking
an ESRC-funded PhD at the Universityof Birmingham on care commissioning.
(02:24):
He was the main researcher on the care
in the Four Nations work packagewithin the SC Sustainable Care Team.
Prior to that,he contributed to the European
Commission's 2018 peer review of Germany'slatest long term care reforms.
Patrick is a former fellowof the King's Fund, where he co-authored
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two publications on social carefor older people.
Before The King's Fund, he worked withthe Department of Health and Social Care.
Local authorities and NHS organisations
on the implementationof the CARE Act 2014.
Hi Patrick.
Her Dan. How are you?
Fine, thank you very much.
It's nice to see youA very good introduction. It's
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was a long one!
We got there in the end.
So as I mentioned earlier, we've cometogether to talk about your new book
entitled Social Care and the UK's FourNations: between Two Paradigms.
So what is social care reformtrying to achieve in all four nations?
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So the
focus of the book is on England,Scotland, Wales and Northern Ireland.
And we're really looking at the periodsince the devolution of powers to those,
not to England, so as not to England,to Scotland, Wales and Northern
Ireland following 1997.
And I guess starting with the realisation
that we now have four reallyquite different care systems in the UK.
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And so we want,we want to understand this kind of
what are some of the key dynamics,what policies have been introduced
and what's the learning thatthere could be across all of the four?
So we undertook research,we looked at policy documents, key
pieces of legislation, white papers,we did interviews with policymakers
in all four of the nationsand some of the people
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from some of the key organisations delivering care and support and care workers and
unpaid carers to really understand
kind of what some of the dynamics wereand what some of the learning would be.
So in terms of kind of what they're tryingto achieve that we would say that in all
four of the nations is a sensethat care is in crisis,
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that this is a kind of long crisis.
It's not one which is kind of really seems
to be coming to a head and being resolved.
It's just a sensethat the systems and services
that we've got inplace were created for a kind of post-war
1945 population that really doesn'treflect the kind of current populations.
So we've kind of conceptualised thisin terms of five care crises,
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which all of whichare responding to a crisis of demand.
So a sense that because of populationageing and demographic change,
there is now this some strainon care systems.
And in response to that we've kind ofwe could talk about a crisis of families.
So assumptions that were made
about the distribution of carewithin families have changed.
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Families, though, continued alongsideother unpaid carers
to make an enormous contributionand be hugely in strain
and in need of increased support.
So we think there's a sort of a crisisthere around the role of the family.
We could say there's a crisisaround the role of the state,
you know, the statein that kind of post-war era.
But lots of institutions
put things in place to support people,but those were not always supports,
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which really allowed people to leadgood lives and were quite problematic.
More recently,we've seen the state kind of pulling away
and reducing funding,and that's also difficult.
And is that to potentially whatwe call the crisis of the market, lots of,
you know, huge proliferation of careproviders, some of whom are kind
of delivering poor quality care on stablefinancial models.
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So we can see thatthere's a problem around the market.
And then the last of all kind of crisesis around community, a sense that
we're all kind of very keenon the development of not for profit
providers of natural community resources
in people's neighbourhoods and livesthat will allow them to,
you know,
move away from thatsense of kind of isolation and loneliness
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and kind of leading good flourishing liveswith a sense of purpose and meaning,
which is really what I thinkall of us would want from life.
But actually there's lots of reasonswhy community is also under strain
and the kind of spaces and placesthat people maybe went to used to go to
to get that support are disappearing.
So in response to that,we then in the nations
say that we think that care policyis trying to achieve
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a number of thingsand actually quite similar things across
all of the four nations.
So in all of them,they've got this language around wellbeing
trying to increase individualand collective wellbeing.
There's a real language about fairnessand what's fair in the social care
space,particularly in relation to funding.
Who should pay, how much should they pay?
If you worked hard
and saved all your life, does that meanthat you ought to get free care services?
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And that's not the case at the momentbecause that means tested.
So there's a lot of discussion aroundfairness.
Rights is another key to narrative around
the sort of human rightsfocus around social capital in Scotland.
That language is usedvery much around rights and entitlements.
There's something around equality,and I think that raises big questions.
Quality for whom are we talking about?
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Quality care servicesfor people in families receiving care,
or are we talking about qualitywork, quality jobs?
Because those thingsabout pulling in different directions?
And then finally,it's about sustainability.
Can this all add up together to a systemthat meets fairness of rights
and wellbeing to a set of arrangementswhich is sustainable for the long term
and actually meet the kind of the demandsthat potentially be in place on a.
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Yeah, so
there are kind of a numberof different ways in which
policymakers and legislatorshave tried to respond in these areas,
and we identified six different
areas or mechanismswhereby they try to achieve
wellbeing, fairness, rights,good quality care and sustainability.
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And so those areas are aroundredistributing costs.
So that's particularly in responseto this idea that the system's unfair
somehow, that, you know,you could have saved up all your life,
you could have worked very hardto, you know, buy a house and then,
you know, all of a suddenit disappears very quickly.
You know, if you had to move intoa care home and personalising support.
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So this idea, the you know,the state institutions are often,
you know, poorly equipped to respondto the needs of individuals.
And actually a kind of a diverserange of provisions should be responded
to very particularneeds of both individuals, communities
and across different
kind of what might be calledclient groups in social care.
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Make working age adults,
people with mental health problemsand older adults supporting carers.
So this this speaks to that ideathat there's a crisis of a family,
that there's a feeling across
the four nations that perhaps family
structures are both in some ways
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doing too much, in that they can't,
they can't meet the needs of their,
but they're also perhaps doing too littleso that they aren't,
you know, they aren't supportedto do the care that they perhaps could do
investing in prevention.
So, you know, that's a big partof the narrative across the four nations.
So intervening earlierin order to prevent people
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from developing social care needs,
integrating with health.
So that's another big part of this.
The social care policy agenda
kind of pushing to make the experiencea lot more.
Joined up when people have to deal withboth the NHS and the health system
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and with the social care system,which is the case for, you know, a large
proportion of people that go into hospitalor often have to try and get a
packagesorted out before they can be discharged.
And so there's also this wide worry about
professionalisation of the workforce.
So that is a problem is identified,
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the social care workforce is underpaid,
has poor conditions
and isn't recognised
as a kind of skilled profession.
And I think there's a lotin all four nations
which try these trying to to pushfor a more professionalised workforce.
And so that might include thingslike workforce regulation
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and enforcement of minimum wages.
So those are those are kind of the,you know, what
all four nations are kind of aiming at,you know, to tackle the the
the problems, the crises of families,
state market and community
through redistributing costs,personalising support,
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supporting carers,inventing them, investing in prevention,
integrating with health professionalsin the work
that we're doing in orderto kind of serve the principles
of wellbeing, fairness,rights, quality and sustainability.
First, thank you for that was really good.
So this book presents for the first timeresearch on the perspectives
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of social care policymakerson the four systems in which they operate
and the ways in which they can borrowfrom one or the other.
But which of the foundations has madethe most progress on social care reform?
So as you can imagine, it's a kind of it'sa it's an it depends
kind of answer, because there's a numberof different ways of looking at it.
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But I mean, one of the waysyou could look at it is sort of who's gone
furthest around some of these key areasthat we talked about, like support
for carers, like integration with health,like we're just redistributing the costs.
And if we do look at that,then we would probably say
that in many waysScotland is the furthest advanced,
at least in terms of its kind ofwhat's going on,
those on the statute booksand the kind of legislation.
So there's obviously
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issues around implementationand that's very difficult and awful.
But one of the things that we would sayis that Scotland's had the most
conducive environment.
So we kind of we've looked at kind of,you know, what some of the factors
might be that kind of make it easy or hardto make progress on care reform.
And I think we've said that on the whole,Scotland has had no,
you know, the most advantageous.
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It's quite small poverty.
So it's had a lot of advantages over,say, England, which is much, much larger,
much more of a kind of complex,adversarial policy system
compared to the other smallernations like Wales or Northern Ireland.
Scotlandhad a lot more institutional stability.
It hasn't had the kind of institutionbuilding that Wales
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has had to do because Wales had a quitekind of anaemic devolution settlement.
It's really had to kind of build on.
And then in Northern Irelandyou've had just long periods
of suspension of the executive andand real difficulty making getting off
the starting blocksin terms of care legislation.
So what they've managed is Scotland,
which we think is probably one ofthe reasons that they've advanced so far,
is have this kind of iterative approachrather than having a big set piece
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act like the CARE Act in England orthe Social Services Lobbying Act in Wales,
that kind of built up slowlywith the free personal care
coming in around 2002,
they've had the Self-Directed Support Act
and then they kind of built upthe legislation over time.
And and I think we would consider
that that's been quite advantageousbecause it's meant
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that some of the people who might opposecertain
elements of reformhaven't had this big target to aim at.
And so I think we think that there'ssome advantage really in this sort
of incremental approach to reformthat's going further in Scotland.
It's kind of understandingthe social care system as a system
rather than just as a kind of,you know, problem to be solved.
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You know, that's that's one of thethe main messages of the book is that
part of understandingsocial care is it as a complex system
is, you know,
is one of the most important thingswhen we're thinking about, you know,
building a more sustainable approachto reform.
And so, you know,there are lots of problems.
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It is difficult kind of respondingto a question about, you know,
who's gone furthest or progressed,you know, because of course,
the response to that is always,you know, confer is for whom?
You know.
And it's like in some ways, you know,Scotland has done the most has been
the most active and kind of had the mostput the most kind of policy attention
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in social care, you know,But there were lots of people
within the system who might say,but what about us?
You know, you know, because you can take,for instance, self-directed
support, you know, where you know,although there's legislation,
perhaps,
you know, the number of peoplewho are able to access that much more kind
of personalised support
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has kind of really stalled in Scotlandin some ways.
So, you know, maybe a younger,
disabled person who's looking for thatmuch more flexible support
might say, well, actually Scotlandhasn't got as far as England in some ways.
So, you know, it's
it's always difficult respondingto those questions about, you know,
who's best who, you know, it's like,you know, who's is best for who, You know,
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because the social care system so diverseand the needs of
a younger, disabled personand perhaps an older person who's frail,
kind of going in and out of hospital,also fundamentally different
that, you know, that questioncould be answered for each of those people
in different ways.
Just a staff question, I suppose.
Is there any particular learningfrom Scotland that the other formations
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could take on right now and list.
Space is quite interestingseeing what's happening in Scotland
with the National Care Service,
which at the moment is paused the reformswith the change in First Minister.
And so it's kind of
one of the thingswe we've been talking about
is whether kind of Scotlandhas got itself a bit unstuck
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because it's now trying to do whatall of the other nations have done,
which is to sort ofhave this big set piece of legislation
where which kind of you just end up
maximising the targetfor the central veto players.
And so you've got this kind of coalitionof, you know, local government.
I like it.
The GP's are like the trade unionsdon't like it,
you know, the the family courts
at one point we're going to be involvedand they didn't like it.
So there's, you know,you kind of suddenly everybody
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saying the reason why that can't happenand you get this momentum around it.
So I think, you know,
the learning perhaps from the othernations and Morrissey from Scotland is
is that incrementalismmay be a better way to go rather than, you
know, we've got this sort of like fixedsocial care for generations,
you know, fix it once and for alltype language from politicians.
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And maybe that isn't the best wayto do it.
But, you know, incrementalismalso is it's risks because, you know,
you get you know, one of the oneof the issues which we found is that each
successive piece of legislation
starts to draw attention awayfrom what went before.
So, you know,you kind of suddenly you're over here
looking at integration with healthand you forgotten that you actually passed
a bill about solidarity supportlike two years ago in Nice
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because suddenly things have moved on.
So, yeah, there's no easy answer, I think.
No, I think that's right.
And I think we probably strikea little bit less of an optimistic tone
if we if we about Scotland,if we were to write the book again now.
And I think it's it'sjust that, you know, the guys of those
veto playerscan be different in different contexts.
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You know, obviously in in the Westminstersystem, that's often the kind of comes
from within the Treasury,you know, those kind of parallel forms of
of government where, you know,they'll they'll kind of,
you know, stiflesomething right at the end of a process
and kind of just say, well, therejust isn't the money for that to happen,
you know, where that kind of
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that kind of siloed stylewhere you get in Westminster is absent.
We kind of in some waysyou'd assume that there wouldn't
be that kind of veto player
dynamic.
But actually, you know, we can see thatwith the kind of going for this big bad
National care Service that kind of createdan opportunity for different types
of veto players, you know,different people within the system.
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It's been interesting kind of see theresponse from local government, you know,
and and from others, particularlythe trade unions
that kind of, you know, calling,you know, once
you kind of build a narrative around,you know, fairness and
and a well-funded centralised system,you know,
you know,
you really have to kind of followthrough on the promises that, you know,
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I think when you when you're
when you're doing somethingwhich is a little bit
more iterative, kind of focusingon different parts of the system,
then that target isn't quite so big.
So I think we're,
we're starts to build a better pictureof why social care reform is so hard.
But is there anything you'd like to addabout why it's so difficult?
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Yeah,I mean, I think one of the key issues is
how the public feels about it,
because it's one thing, you know,we can talk about sort of the
some of the institutional barriers,but often it's about the kind of how much
political capital or are leaderswilling to spend on social care
because we've just had this repeatedpattern
in England of kind of politicianssay they're going to sort it.
They pass a piece of legislation which,you know, something like the cap, cap,
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you know, has been passedinto primary legislation twice now.
And nonetheless,
you know, it's now looking very unlikelythat it's ever going to happen.
And partly
that's because, you know, the costswe know that
if we'd had the natural slavery, you know,it would have been cut upfront costs
on certain benefitsfor a few people down the line.
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And so politicians are not willing,
I think, to expand the right amountof political capital on it
and have the kind of political couragethat it takes.
So it's something about changing,I think the whole public debate around it,
making it, you know, tryingto raise its profile, visiting the NHS,
which obviously does have a much higherpolitical profile and public support,
and are the first peopleto think about how that might be done.
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But yeah, it is a tricky one.
I mean, it's one of those areaswhich is so easy to exploit
within a very adversarial
political system, you know,which is why we've seen kind of, you know,
in previous election campaigns,you know, the death tax with,
you know, images of, you know, gravestonesand all of this sort of thing.
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Is that that's part of the reasonwhy it's so difficult, you know, to
do to kind of there are lots of kindof psychological reasons why,
you know, dealing with social care isn'tan attractive prospect for politicians.
It's not kind of,you know, a positive and sexy sort of,
you know, future futurelooking is about sustainability,
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about the kind of societythat we want to live in.
It's difficult, you know, it'svery it's difficult and kind of involves,
you know,negotiation of different interests.
So that's the you know,there are lots of reasons why,
You know, I think what we would wantto say is that, you know, social care
reform is is as much about kindof trying to anticipate some of those
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potential institutional barriersto reform before
you even think about what the visionfor for a social care future is.
Well, thank you for that.
So let's talk about thethe overall contribution of the book
so policymakers can decidebetween two paradigms.
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Do they want care to be more standardised,regulated, formulas centralised, or
do they want it to be more differentiatedthough more informal and personalised?
Yeah.
So that's the you know, is the kind ofthe conclusion of the book is that,
you know,when we're speaking to policymakers
is that they tend to, when they're talkingabout a vision for social care,
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refer to a kind of a
one kind of coherent vision for another.
And those two visionskind of come together
as what we call differentiatedand standardised.
So on the one hand,a kind of personal life system
which puts, you know,the service user at the centre of what
the system does, you know,is kind of commissioned at the frontline
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with very small packageswhich are directed by service users
which focus on community assets,community strengths and so on.
And then a kind of another paradigm,another set of narratives which are around
institutional power
about kind of becoming the system,becoming better regulated, more
consistent, safer, you know, recognising
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and professionalising the workforce.
And you know, what we want to say is that,you know, there were a lot of tensions
between those two things. You know, if,
if a system wants to pursuea very, very personalised system,
then perhaps, you know, kind of regulatingcare workers wouldn't be the way to go.
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And I think what we see is in the policydocuments is a combination
of these two paradigms, you know,and they sit together
without recognisingsome of the tensions between them.
And I think that's what, whatwe'd like to see in all of the systems is,
is some kind of process for negotiatingbetween these these tensions.
So thinking about them in an open way.
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Great.
Thank you.
Are there any any other recommendationsfor policymakers
that you like to emphasisebased on the findings in the book?
I mean, I think, you know, we're lucky keycontributions is to say
let's sort of facethese two paradigms explicitly
and rather than trying to sort of pretendwe can have the best of both worlds,
say, well,maybe we have to make some choices
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or some trade offs and prioritiseone one way of doing things over another.
So there's a really interesting exchangein the Scottish Parliament where
Watson from Glasgow Universityasks Derek Feeney, who'd written the fair,
the report which precededthe National Care Service proposals.
He so said, You know, subversiveis what we found in the other nations.
This idea of kind of, you know, there'stwo things running through the 50 report.
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One is about co-productionpersonalisation,
the others about kind of regulation andand safety
and consistency and, you know,they don't seem to fit together very well.
And, you know, Derek Feely said haveresponded well, but we've got to do both.
And that may be true.
But I guess what we you know,what is the missing bit is sort of, well,
you know, how do we
what are the kind of conversationshere needs to be about, you know, in
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what's the scale, first of all, ofdo you do this in the Scottish Parliament?
Do you do it in local authorities?
You know, do we do it at Westminster?
So some of these different issues willneed to be resolved at different levels.
So if you know, if we're talking about
bringing in more tax funding,that's got to be done by Westminster.
You know, if we're talking aboutwhat do people get to choose in terms
of how they spend their days,are they supported?
(24:44):
Let's make that as little as possible.
But yeah, let's at least tryand be explicit about the fact
that there are tensions hereand we need to kind of make sure
we've got the right peopleas part of the conversation.
So, you know, if somebody is, you know,the people who are using services
and accessing support
need to be part of that conversationabout what should be prioritised.
And often
(25:04):
when you speak to people about that,some of the stuff around
safety and consistency isn't necessarilypeople's top priority because,
you know, good social care
is about flourishing lives, it'sabout getting out there and having a life.
And that might be about saying, well,how do we sort of support people around
positive risk taking and, you know,more kind of person centred support.
You know, and we do knowthat people institute in institutions
(25:26):
is almost never the wayto achieve any of those things.
So I think we say that,well, let's try and move away from,
you know, assuming thatkind of consistency is good in its own
right and safety is almostalways the most important thing.
Yeah, it's interesting, isn't it?
Because you know, the you know,there are dangers with it with both.
You know, it's kind of like, you know, fora differentiate, differentiate paradigm,
(25:49):
you know, there are risks involvedin terms of kind of
safety and about kind of inconsistencyand things like that.
And there are dangers with a morestandardised, safe, quote unquote system
in the it can kind of,
you know, make people feel excluded,make people feel part of institutions
rather than part of society, you know, So
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it's about recognising that actuallythese are kind of two different visions
which exist at the same time in tensionwith one another.
And they are and they're often reflectiveof different interests, you know,
the kind of interests of a frail 95 yearold kind of going in and out of hospital,
you know, would be one thingwhich might involve, you know,
a much safer, much smootherinstitutional transitions,
(26:34):
things like that, much moreprofessionalised workforce around them.
They might be served much better by thatkind of more standardised paradigm.
But again, like Catherine said,that wouldn't be, you know,
the ideal for the needs of a younger,disabled person who wants,
you know, to go out with their mates,who wants to find a job,
he wants to be included and,
you know, and live a kind of a fuller,more inclusive life.
(26:57):
And that's, you know, we,we do have to, you know, in some ways
feel is right that, you know,the social care system as a whole
needs to try and do both and serve both.
But, you know, we've got to recognisethat sometimes instead of being one,
you know, we've only got limited resourcesand we don't serve another community.
And that that needs to bea negotiated process
(27:19):
whereby we think about where resourcesgo in the system.
You know,and I think as well, you know, I guess
because there has been
a poverty of expectations aroundwhat older people can expect,
we say, you know, old peoplewant to go out with their mates as well.
Let's make that happen
now. You're right.
You're right.
Yeah.
I mean, it's yeah, that'sI mean, that again, that's
that's the whole type of conversationthat needs to be had.
(27:42):
You know, it's like actually,
you know, those who advocateon behalf of older people want, you know,
swing towards a standardised paradigm,
but actually maybethey're making a mistake in doing that.
You know, maybe that isn'twhat all of the people don't really want.
But, you know, I think it's about,
yeah, having that conversationin a kind of a democratic setting,
you know, which is kind of more iterativeand deliberative than this
(28:05):
idea of kind of doing things,fixing everything
through a kind of one offbig bang piece of legislation.
And I thought we thinkis kind of both a mistake in terms of the
the narrative of it,but also the kind of yeah,
the task as wellalways is misguided because it's
it's kind of
(28:25):
bound to fail because ofsome of these institutional barriers.
While thank you forjust before we wrap up,
I think our viewers will be
now very interestedto know more about the book
and whether they can gethold of a copy. Yes.
So it's available on the policyPress website.
There's a hardback and an e-bookand there's two other chapters
(28:46):
are available, Open Access, which you canjust get from the Policy press website.
So and we picked two chapters that wethink some kind of nice parts of the book.
So one of them, chapter four, is about ourkey findings, which are the foundations.
And then Chapter seven is about thisnotion of the two paradigms and how
they come together and the intentionand how we might move on from them.
So yes, so people might want to just dipinto those open access chapters
(29:10):
or there's the option to get.
The book and we'll put all the linksup on the web page with this
with this podcast as well,so people can find that.
Thank you very much.That an absolute pleasure.
Thank you, Catherine. Thanks, Dan.
Thanks, Patrick. Thanks. Dan.
Thanks for having us.
The Care Matters podcast is
brought to youby the ESRC Centre for Care and CIRCLE,
the Centre for International Researchon Care, Labour
and Equalities.
In this series,
our researchers welcome expertsin the field and those giving or receiving
care to discuss crucial issuesin social care as we collectively attempt
(00:30):
to make a positive differenceto how care is experienced
and provided.
Hello
and welcome to this episode of the CareMatters Podcast.
I'm Dan Williamson.
I'm the producer of the podcastand the digital and communications
(00:50):
coordinatorfor the ESRC Centre for Care and CIRCLE.
For today's episode,
I am pleased to be joinedby two colleagues
whom I've worked withfor a number of years, starting during
the ESRC-funded Sustainable Care program,
which ran from 2017 to 2021,
and they've authored a book detailingresearch and findings
(01:12):
carried out during the program,entitled ‘Social Care
and the UK's Four NationsBetween Two Paradigms’.
And this is what we've cometogether today to discuss.
Catherine Needham
is professor of Public Policyand Public Management
at the Health Services Management Centreat the University of Birmingham.
Her research focuses on social care,including personal isolation,
(01:36):
co-production, personal budgetsand care markets.
She's published a wide range of articles,chapters
and books for academic and practitioneraudiences.
Katherine led the care in the Four Nations
work package within the ESRCSustainable Care Team.
She's now leading research on care systemsas part of the ESRC Centre for Care
(02:00):
and is also a member of IMPACT,The UK Centre
for Evidence Implementationin Adult Social Care.
Welcome, Catherine.
Thanks, Dan And we also have with us todayPatrick Hall.
Patrick is a social care policy researchercurrently undertaking
an ESRC-funded PhD at the Universityof Birmingham on care commissioning.
(02:24):
He was the main researcher on the care
in the Four Nations work packagewithin the SC Sustainable Care Team.
Prior to that,he contributed to the European
Commission's 2018 peer review of Germany'slatest long term care reforms.
Patrick is a former fellowof the King's Fund, where he co-authored
(02:45):
two publications on social carefor older people.
Before The King's Fund, he worked withthe Department of Health and Social Care.
Local authorities and NHS organisations
on the implementationof the CARE Act 2014.
Hi Patrick.
Her Dan. How are you?
Fine, thank you very much.
It's nice to see youA very good introduction. It's
(03:09):
was a long one!
We got there in the end.
So as I mentioned earlier, we've cometogether to talk about your new book
entitled Social Care and the UK's FourNations: between Two Paradigms.
So what is social care reformtrying to achieve in all four nations?
(03:30):
So the
focus of the book is on England,Scotland, Wales and Northern Ireland.
And we're really looking at the periodsince the devolution of powers to those,
not to England, so as not to England,to Scotland, Wales and Northern
Ireland following 1997.
And I guess starting with the realisation
that we now have four reallyquite different care systems in the UK.
(03:50):
And so we want,we want to understand this kind of
what are some of the key dynamics,what policies have been introduced
and what's the learning thatthere could be across all of the four?
So we undertook research,we looked at policy documents, key
pieces of legislation, white papers,we did interviews with policymakers
in all four of the nationsand some of the people
(04:10):
from some of the key organisations delivering care and support and care workers and
unpaid carers to really understand
kind of what some of the dynamics wereand what some of the learning would be.
So in terms of kind of what they're tryingto achieve that we would say that in all
four of the nations is a sensethat care is in crisis,
(04:31):
that this is a kind of long crisis.
It's not one which is kind of really seems
to be coming to a head and being resolved.
It's just a sensethat the systems and services
that we've got inplace were created for a kind of post-war
1945 population that really doesn'treflect the kind of current populations.
So we've kind of conceptualised thisin terms of five care crises,
(04:52):
which all of whichare responding to a crisis of demand.
So a sense that because of populationageing and demographic change,
there is now this some strainon care systems.
And in response to that we've kind ofwe could talk about a crisis of families.
So assumptions that were made
about the distribution of carewithin families have changed.
(05:12):
Families, though, continued alongsideother unpaid carers
to make an enormous contributionand be hugely in strain
and in need of increased support.
So we think there's a sort of a crisisthere around the role of the family.
We could say there's a crisisaround the role of the state,
you know, the statein that kind of post-war era.
But lots of institutions
put things in place to support people,but those were not always supports,
(05:35):
which really allowed people to leadgood lives and were quite problematic.
More recently,we've seen the state kind of pulling away
and reducing funding,and that's also difficult.
And is that to potentially whatwe call the crisis of the market, lots of,
you know, huge proliferation of careproviders, some of whom are kind
of delivering poor quality care on stablefinancial models.
(05:56):
So we can see thatthere's a problem around the market.
And then the last of all kind of crisesis around community, a sense that
we're all kind of very keenon the development of not for profit
providers of natural community resources
in people's neighbourhoods and livesthat will allow them to,
you know,
move away from thatsense of kind of isolation and loneliness
(06:17):
and kind of leading good flourishing liveswith a sense of purpose and meaning,
which is really what I thinkall of us would want from life.
But actually there's lots of reasonswhy community is also under strain
and the kind of spaces and placesthat people maybe went to used to go to
to get that support are disappearing.
So in response to that,we then in the nations
say that we think that care policyis trying to achieve
(06:39):
a number of thingsand actually quite similar things across
all of the four nations.
So in all of them,they've got this language around wellbeing
trying to increase individualand collective wellbeing.
There's a real language about fairnessand what's fair in the social care
space,particularly in relation to funding.
Who should pay, how much should they pay?
If you worked hard
and saved all your life, does that meanthat you ought to get free care services?
(07:01):
And that's not the case at the momentbecause that means tested.
So there's a lot of discussion aroundfairness.
Rights is another key to narrative around
the sort of human rightsfocus around social capital in Scotland.
That language is usedvery much around rights and entitlements.
There's something around equality,and I think that raises big questions.
Quality for whom are we talking about?
(07:22):
Quality care servicesfor people in families receiving care,
or are we talking about qualitywork, quality jobs?
Because those thingsabout pulling in different directions?
And then finally,it's about sustainability.
Can this all add up together to a systemthat meets fairness of rights
and wellbeing to a set of arrangementswhich is sustainable for the long term
and actually meet the kind of the demandsthat potentially be in place on a.
(07:45):
Yeah, so
there are kind of a numberof different ways in which
policymakers and legislatorshave tried to respond in these areas,
and we identified six different
areas or mechanismswhereby they try to achieve
wellbeing, fairness, rights,good quality care and sustainability.
(08:08):
And so those areas are aroundredistributing costs.
So that's particularly in responseto this idea that the system's unfair
somehow, that, you know,you could have saved up all your life,
you could have worked very hardto, you know, buy a house and then,
you know, all of a suddenit disappears very quickly.
You know, if you had to move intoa care home and personalising support.
(08:29):
So this idea, the you know,the state institutions are often,
you know, poorly equipped to respondto the needs of individuals.
And actually a kind of a diverserange of provisions should be responded
to very particularneeds of both individuals, communities
and across different
kind of what might be calledclient groups in social care.
(08:51):
Make working age adults,
people with mental health problemsand older adults supporting carers.
So this this speaks to that ideathat there's a crisis of a family,
that there's a feeling across
the four nations that perhaps family
structures are both in some ways
(09:12):
doing too much, in that they can't,
they can't meet the needs of their,
but they're also perhaps doing too littleso that they aren't,
you know, they aren't supportedto do the care that they perhaps could do
investing in prevention.
So, you know, that's a big partof the narrative across the four nations.
So intervening earlierin order to prevent people
(09:35):
from developing social care needs,
integrating with health.
So that's another big part of this.
The social care policy agenda
kind of pushing to make the experiencea lot more.
Joined up when people have to deal withboth the NHS and the health system
(09:55):
and with the social care system,which is the case for, you know, a large
proportion of people that go into hospitalor often have to try and get a
packagesorted out before they can be discharged.
And so there's also this wide worry about
professionalisation of the workforce.
So that is a problem is identified,
(10:17):
the social care workforce is underpaid,
has poor conditions
and isn't recognised
as a kind of skilled profession.
And I think there's a lotin all four nations
which try these trying to to pushfor a more professionalised workforce.
And so that might include thingslike workforce regulation
(10:40):
and enforcement of minimum wages.
So those are those are kind of the,you know, what
all four nations are kind of aiming at,you know, to tackle the the
the problems, the crises of families,
state market and community
through redistributing costs,personalising support,
(11:00):
supporting carers,inventing them, investing in prevention,
integrating with health professionalsin the work
that we're doing in orderto kind of serve the principles
of wellbeing, fairness,rights, quality and sustainability.
First, thank you for that was really good.
So this book presents for the first timeresearch on the perspectives
(11:22):
of social care policymakerson the four systems in which they operate
and the ways in which they can borrowfrom one or the other.
But which of the foundations has madethe most progress on social care reform?
So as you can imagine, it's a kind of it'sa it's an it depends
kind of answer, because there's a numberof different ways of looking at it.
(11:44):
But I mean, one of the waysyou could look at it is sort of who's gone
furthest around some of these key areasthat we talked about, like support
for carers, like integration with health,like we're just redistributing the costs.
And if we do look at that,then we would probably say
that in many waysScotland is the furthest advanced,
at least in terms of its kind ofwhat's going on,
those on the statute booksand the kind of legislation.
So there's obviously
(12:05):
issues around implementationand that's very difficult and awful.
But one of the things that we would sayis that Scotland's had the most
conducive environment.
So we kind of we've looked at kind of,you know, what some of the factors
might be that kind of make it easy or hardto make progress on care reform.
And I think we've said that on the whole,Scotland has had no,
you know, the most advantageous.
(12:25):
It's quite small poverty.
So it's had a lot of advantages over,say, England, which is much, much larger,
much more of a kind of complex,adversarial policy system
compared to the other smallernations like Wales or Northern Ireland.
Scotlandhad a lot more institutional stability.
It hasn't had the kind of institutionbuilding that Wales
(12:46):
has had to do because Wales had a quitekind of anaemic devolution settlement.
It's really had to kind of build on.
And then in Northern Irelandyou've had just long periods
of suspension of the executive andand real difficulty making getting off
the starting blocksin terms of care legislation.
So what they've managed is Scotland,
which we think is probably one ofthe reasons that they've advanced so far,
is have this kind of iterative approachrather than having a big set piece
(13:09):
act like the CARE Act in England orthe Social Services Lobbying Act in Wales,
that kind of built up slowlywith the free personal care
coming in around 2002,
they've had the Self-Directed Support Act
and then they kind of built upthe legislation over time.
And and I think we would consider
that that's been quite advantageousbecause it's meant
(13:30):
that some of the people who might opposecertain
elements of reformhaven't had this big target to aim at.
And so I think we think that there'ssome advantage really in this sort
of incremental approach to reformthat's going further in Scotland.
It's kind of understandingthe social care system as a system
rather than just as a kind of,you know, problem to be solved.
(13:51):
You know, that's that's one of thethe main messages of the book is that
part of understandingsocial care is it as a complex system
is, you know,
is one of the most important thingswhen we're thinking about, you know,
building a more sustainable approachto reform.
And so, you know,there are lots of problems.
(14:14):
It is difficult kind of respondingto a question about, you know,
who's gone furthest or progressed,you know, because of course,
the response to that is always,you know, confer is for whom?
You know.
And it's like in some ways, you know,Scotland has done the most has been
the most active and kind of had the mostput the most kind of policy attention
(14:34):
in social care, you know,But there were lots of people
within the system who might say,but what about us?
You know, you know, because you can take,for instance, self-directed
support, you know, where you know,although there's legislation,
perhaps,
you know, the number of peoplewho are able to access that much more kind
of personalised support
(14:57):
has kind of really stalled in Scotlandin some ways.
So, you know, maybe a younger,
disabled person who's looking for thatmuch more flexible support
might say, well, actually Scotlandhasn't got as far as England in some ways.
So, you know, it's
it's always difficult respondingto those questions about, you know,
who's best who, you know, it's like,you know, who's is best for who, You know,
(15:19):
because the social care system so diverseand the needs of
a younger, disabled personand perhaps an older person who's frail,
kind of going in and out of hospital,also fundamentally different
that, you know, that questioncould be answered for each of those people
in different ways.
Just a staff question, I suppose.
Is there any particular learningfrom Scotland that the other formations
(15:42):
could take on right now and list.
Space is quite interestingseeing what's happening in Scotland
with the National Care Service,
which at the moment is paused the reformswith the change in First Minister.
And so it's kind of
one of the thingswe we've been talking about
is whether kind of Scotlandhas got itself a bit unstuck
(16:02):
because it's now trying to do whatall of the other nations have done,
which is to sort ofhave this big set piece of legislation
where which kind of you just end up
maximising the targetfor the central veto players.
And so you've got this kind of coalitionof, you know, local government.
I like it.
The GP's are like the trade unionsdon't like it,
you know, the the family courts
at one point we're going to be involvedand they didn't like it.
So there's, you know,you kind of suddenly everybody
(16:23):
saying the reason why that can't happenand you get this momentum around it.
So I think, you know,
the learning perhaps from the othernations and Morrissey from Scotland is
is that incrementalismmay be a better way to go rather than, you
know, we've got this sort of like fixedsocial care for generations,
you know, fix it once and for alltype language from politicians.
(16:45):
And maybe that isn't the best wayto do it.
But, you know, incrementalismalso is it's risks because, you know,
you get you know, one of the oneof the issues which we found is that each
successive piece of legislation
starts to draw attention awayfrom what went before.
So, you know,you kind of suddenly you're over here
looking at integration with healthand you forgotten that you actually passed
a bill about solidarity supportlike two years ago in Nice
(17:05):
because suddenly things have moved on.
So, yeah, there's no easy answer, I think.
No, I think that's right.
And I think we probably strikea little bit less of an optimistic tone
if we if we about Scotland,if we were to write the book again now.
And I think it's it'sjust that, you know, the guys of those
veto playerscan be different in different contexts.
(17:27):
You know, obviously in in the Westminstersystem, that's often the kind of comes
from within the Treasury,you know, those kind of parallel forms of
of government where, you know,they'll they'll kind of,
you know, stiflesomething right at the end of a process
and kind of just say, well, therejust isn't the money for that to happen,
you know, where that kind of
(17:48):
that kind of siloed stylewhere you get in Westminster is absent.
We kind of in some waysyou'd assume that there wouldn't
be that kind of veto player
dynamic.
But actually, you know, we can see thatwith the kind of going for this big bad
National care Service that kind of createdan opportunity for different types
of veto players, you know,different people within the system.
(18:10):
It's been interesting kind of see theresponse from local government, you know,
and and from others, particularlythe trade unions
that kind of, you know, calling,you know, once
you kind of build a narrative around,you know, fairness and
and a well-funded centralised system,you know,
you know,
you really have to kind of followthrough on the promises that, you know,
(18:32):
I think when you when you're
when you're doing somethingwhich is a little bit
more iterative, kind of focusingon different parts of the system,
then that target isn't quite so big.
So I think we're,
we're starts to build a better pictureof why social care reform is so hard.
But is there anything you'd like to addabout why it's so difficult?
(18:54):
Yeah,I mean, I think one of the key issues is
how the public feels about it,
because it's one thing, you know,we can talk about sort of the
some of the institutional barriers,but often it's about the kind of how much
political capital or are leaderswilling to spend on social care
because we've just had this repeatedpattern
in England of kind of politicianssay they're going to sort it.
They pass a piece of legislation which,you know, something like the cap, cap,
(19:17):
you know, has been passedinto primary legislation twice now.
And nonetheless,
you know, it's now looking very unlikelythat it's ever going to happen.
And partly
that's because, you know, the costswe know that
if we'd had the natural slavery, you know,it would have been cut upfront costs
on certain benefitsfor a few people down the line.
(19:38):
And so politicians are not willing,
I think, to expand the right amountof political capital on it
and have the kind of political couragethat it takes.
So it's something about changing,I think the whole public debate around it,
making it, you know, tryingto raise its profile, visiting the NHS,
which obviously does have a much higherpolitical profile and public support,
and are the first peopleto think about how that might be done.
(19:59):
But yeah, it is a tricky one.
I mean, it's one of those areaswhich is so easy to exploit
within a very adversarial
political system, you know,which is why we've seen kind of, you know,
in previous election campaigns,you know, the death tax with,
you know, images of, you know, gravestonesand all of this sort of thing.
(20:19):
Is that that's part of the reasonwhy it's so difficult, you know, to
do to kind of there are lots of kindof psychological reasons why,
you know, dealing with social care isn'tan attractive prospect for politicians.
It's not kind of,you know, a positive and sexy sort of,
you know, future futurelooking is about sustainability,
(20:40):
about the kind of societythat we want to live in.
It's difficult, you know, it'svery it's difficult and kind of involves,
you know,negotiation of different interests.
So that's the you know,there are lots of reasons why,
You know, I think what we would wantto say is that, you know, social care
reform is is as much about kindof trying to anticipate some of those
(21:02):
potential institutional barriersto reform before
you even think about what the visionfor for a social care future is.
Well, thank you for that.
So let's talk about thethe overall contribution of the book
so policymakers can decidebetween two paradigms.
(21:23):
Do they want care to be more standardised,regulated, formulas centralised, or
do they want it to be more differentiatedthough more informal and personalised?
Yeah.
So that's the you know, is the kind ofthe conclusion of the book is that,
you know,when we're speaking to policymakers
is that they tend to, when they're talkingabout a vision for social care,
(21:47):
refer to a kind of a
one kind of coherent vision for another.
And those two visionskind of come together
as what we call differentiatedand standardised.
So on the one hand,a kind of personal life system
which puts, you know,the service user at the centre of what
the system does, you know,is kind of commissioned at the frontline
(22:10):
with very small packageswhich are directed by service users
which focus on community assets,community strengths and so on.
And then a kind of another paradigm,another set of narratives which are around
institutional power
about kind of becoming the system,becoming better regulated, more
consistent, safer, you know, recognising
(22:34):
and professionalising the workforce.
And you know, what we want to say is that,you know, there were a lot of tensions
between those two things. You know, if,
if a system wants to pursuea very, very personalised system,
then perhaps, you know, kind of regulatingcare workers wouldn't be the way to go.
(22:54):
And I think what we see is in the policydocuments is a combination
of these two paradigms, you know,and they sit together
without recognisingsome of the tensions between them.
And I think that's what, whatwe'd like to see in all of the systems is,
is some kind of process for negotiatingbetween these these tensions.
So thinking about them in an open way.
(23:18):
Great.
Thank you.
Are there any any other recommendationsfor policymakers
that you like to emphasisebased on the findings in the book?
I mean, I think, you know, we're lucky keycontributions is to say
let's sort of facethese two paradigms explicitly
and rather than trying to sort of pretendwe can have the best of both worlds,
say, well,maybe we have to make some choices
(23:38):
or some trade offs and prioritiseone one way of doing things over another.
So there's a really interesting exchangein the Scottish Parliament where
Watson from Glasgow Universityasks Derek Feeney, who'd written the fair,
the report which precededthe National Care Service proposals.
He so said, You know, subversiveis what we found in the other nations.
This idea of kind of, you know, there'stwo things running through the 50 report.
(23:59):
One is about co-productionpersonalisation,
the others about kind of regulation andand safety
and consistency and, you know,they don't seem to fit together very well.
And, you know, Derek Feely said haveresponded well, but we've got to do both.
And that may be true.
But I guess what we you know,what is the missing bit is sort of, well,
you know, how do we
what are the kind of conversationshere needs to be about, you know, in
(24:22):
what's the scale, first of all, ofdo you do this in the Scottish Parliament?
Do you do it in local authorities?
You know, do we do it at Westminster?
So some of these different issues willneed to be resolved at different levels.
So if you know, if we're talking about
bringing in more tax funding,that's got to be done by Westminster.
You know, if we're talking aboutwhat do people get to choose in terms
of how they spend their days,are they supported?
(24:44):
Let's make that as little as possible.
But yeah, let's at least tryand be explicit about the fact
that there are tensions hereand we need to kind of make sure
we've got the right peopleas part of the conversation.
So, you know, if somebody is, you know,the people who are using services
and accessing support
need to be part of that conversationabout what should be prioritised.
And often
(25:04):
when you speak to people about that,some of the stuff around
safety and consistency isn't necessarilypeople's top priority because,
you know, good social care
is about flourishing lives, it'sabout getting out there and having a life.
And that might be about saying, well,how do we sort of support people around
positive risk taking and, you know,more kind of person centred support.
You know, and we do knowthat people institute in institutions
(25:26):
is almost never the wayto achieve any of those things.
So I think we say that,well, let's try and move away from,
you know, assuming thatkind of consistency is good in its own
right and safety is almostalways the most important thing.
Yeah, it's interesting, isn't it?
Because you know, the you know,there are dangers with it with both.
You know, it's kind of like, you know, fora differentiate, differentiate paradigm,
(25:49):
you know, there are risks involvedin terms of kind of
safety and about kind of inconsistencyand things like that.
And there are dangers with a morestandardised, safe, quote unquote system
in the it can kind of,
you know, make people feel excluded,make people feel part of institutions
rather than part of society, you know, So
(26:11):
it's about recognising that actuallythese are kind of two different visions
which exist at the same time in tensionwith one another.
And they are and they're often reflectiveof different interests, you know,
the kind of interests of a frail 95 yearold kind of going in and out of hospital,
you know, would be one thingwhich might involve, you know,
a much safer, much smootherinstitutional transitions,
(26:34):
things like that, much moreprofessionalised workforce around them.
They might be served much better by thatkind of more standardised paradigm.
But again, like Catherine said,that wouldn't be, you know,
the ideal for the needs of a younger,disabled person who wants,
you know, to go out with their mates,who wants to find a job,
he wants to be included and,
you know, and live a kind of a fuller,more inclusive life.
(26:57):
And that's, you know, we,we do have to, you know, in some ways
feel is right that, you know,the social care system as a whole
needs to try and do both and serve both.
But, you know, we've got to recognisethat sometimes instead of being one,
you know, we've only got limited resourcesand we don't serve another community.
And that that needs to bea negotiated process
(27:19):
whereby we think about where resourcesgo in the system.
You know,and I think as well, you know, I guess
because there has been
a poverty of expectations aroundwhat older people can expect,
we say, you know, old peoplewant to go out with their mates as well.
Let's make that happen
now. You're right.
You're right.
Yeah.
I mean, it's yeah, that'sI mean, that again, that's
that's the whole type of conversationthat needs to be had.
(27:42):
You know, it's like actually,
you know, those who advocateon behalf of older people want, you know,
swing towards a standardised paradigm,
but actually maybethey're making a mistake in doing that.
You know, maybe that isn'twhat all of the people don't really want.
But, you know, I think it's about,
yeah, having that conversationin a kind of a democratic setting,
you know, which is kind of more iterativeand deliberative than this
(28:05):
idea of kind of doing things,fixing everything
through a kind of one offbig bang piece of legislation.
And I thought we thinkis kind of both a mistake in terms of the
the narrative of it,but also the kind of yeah,
the task as wellalways is misguided because it's
it's kind of
(28:25):
bound to fail because ofsome of these institutional barriers.
While thank you forjust before we wrap up,
I think our viewers will be
now very interestedto know more about the book
and whether they can gethold of a copy. Yes.
So it's available on the policyPress website.
There's a hardback and an e-bookand there's two other chapters
(28:46):
are available, Open Access, which you canjust get from the Policy press website.
So and we picked two chapters that wethink some kind of nice parts of the book.
So one of them, chapter four, is about ourkey findings, which are the foundations.
And then Chapter seven is about thisnotion of the two paradigms and how
they come together and the intentionand how we might move on from them.
So yes, so people might want to just dipinto those open access chapters
(29:10):
or there's the option to get.
The book and we'll put all the linksup on the web page with this
with this podcast as well,so people can find that.
Thank you very much.That an absolute pleasure.
Thank you, Catherine. Thanks, Dan.
Thanks, Patrick. Thanks. Dan.
Thanks for having us.
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