This book is about ‘adult social care’ in England – the term commonly used to refer to personal care and practical support for older people and adults with physical disabilities, learning disabilities or mental health issues, as well as support for those caring for them informally. Much of the debate about adult social care tends to concentrate on the situation of older people, even though social care expenditure on adults of working age and older people is roughly equal in size. The focus is also on England. Although all parts of the UK have followed the same policy trajectory to some extent, this has become less so in the wake of devolution. While reference will be made to variations across the UK, this is not a comparative policy analysis. The terms ‘personal care’ and ‘practical support’ are also significant: the former is narrower than the latter, and both are restrictive compared to a wider concept such as ‘well-being’. All of these definitions and their implications will be explored.

It is also a sector of considerable economic significance, enormous policy complexity and seeming political impenetrability. In terms of size, one recent estimate (IFC Consulting, 2018) put the total economic value of the sector at almost £50 billion. The workforce is estimated to be around 1.5 million – a massive source of employment. Moreover, it is estimated that if the adult social care workforce grows proportionally to the projected number of people aged 65 and over in the population, then the number of adult social care jobs will increase to around 2.2 million jobs by 2035 (Skills for Care, 2019). Better healthcare has also improved the life expectancy of people with physical and learning disabilities, meaning that more working-age adults are now in need of social care support. These adults are also less likely than older adults to have financial assets that disqualify them from receiving publicly funded care (NHS Digital, 2019b).

Political and policy responses to a sector of such significance have been contradictory. On the one hand, it has been subjected to massive ideological change in the way support is commissioned and delivered; on the other hand, the long-running debate around funding long-term care has been inconclusive.

Introduction

Developments in adult social care in the 1980s did not emerge in isolation from wider policies in the public realm. Although the public sector has always bought goods and services from the private sector, the influence of neoliberal ideas in the 1980s opened up the debate on whether this should go further than hitherto. In the 1979 Conservative government's first legislative programme, the principle of compulsory competitive tendering for building work was introduced by the Planning and Local Government Act 1980; this principle was later extended to most local authority direct labour work under the Local Government Act 1988. In the same year, the Housing Reform Act encouraged council tenants to ‘opt out’ of local authority control by choosing new landlords (termed ‘housing action trusts’) in the not-for-profit sector. Meanwhile, changes in the NHS were not dissimilar, with organisational responsibility for funding and managing service delivery separated through a ‘purchaser–provider split’.

Underpinning these ideas was the emergent concept of ‘new public management’ (Hood, 1995). This also proposed a quasi-market structure, whereby public and private service providers competed with each other in an attempt to provide better and faster services. Other core themes included: a strong focus on financial control, value for money and increasing efficiency; introducing audits at both financial and professional levels to review performance; greater customer orientation and responsiveness; increasing the scope of roles played by non-public sector providers; deregulating the labour market; discouraging the self-regulatory power of professionals; and handing over power from management to individuals. If neoliberalism provided the ideological framework, new public management offered the means of delivery.

In the social care context, a key landmark was the speech in 1984 by the then Secretary of State for Health, Norman Fowler (1984), extolling the virtues of the ‘enabling role’ of local government. He suggested that social services departments should switch their focus from the direct provision of care to the funding and facilitation of the delivery of care. Accordingly, he set out three roles for social services departments and the wider local council remit:

• • a comprehensive strategic view of all available sources of care;

• • a recognition that social services were only part of the local pattern; and

• • a recognition that social services should support and promote the fullest possible participation of the other different sources of care that exist or can be called into being.

Introduction

Chapter 2 charted the emergence and consolidation of the privatisation of provision of adult social care in England. This has resulted in significant investment by private businesses, especially in residential and nursing care. The precise amounts are difficult to estimate but some within the sector put it at around £30 billion and rising (LaingBuisson, 2014). This is a significant amount and if the money saved by the Treasury had gone into other ways of boosting adult social care, there would be no talk of it being ‘in crisis’. In considering some of the problems thrown up by the privatisation of provision, it is therefore important not to undervalue the scale of this investment. Those hoping for a rapid and substantial ‘renationalisation’ of the sector would certainly have to make a calculation of the sums expended and the costs of compensation that would be required. Chapter 5 examines this issue further.

Nevertheless, this situation has also created problems that would probably have been less likely to occur with a state-run model. Four such concerns will be examined in this chapter: availability; fragility; exploitation and profiteering; and workforce issues.

Availability

Chapter 3 questioned whether the services and support commissioned are well suited to meeting individual needs and preferences, and examined the declining resource base available for the purchase of provision. However, since private businesses will only operate where the financial rewards are deemed acceptable, there are liable to be problems relating to the availability of any form of care in some places. Evidence suggests that care home places are disappearing from areas that already have a shortfall of beds, while new high-quality facilities are opening for those who can pay their own way – a distinct two-tier system in every respect (CSI Market Intelligence, 2020). Indeed, a CSI Market Intelligence (2020) report notes that of the 20 local authorities that gained most beds, ten were already oversupplied, and at the other end of the scale, 12 out of the 20 local authorities that lost the most beds were already undersupplied.

Introduction

This is a chapter that was not envisaged when the proposal for this book was submitted in 2019. Much has happened since then, and continues to evolve; therefore, this chapter can still be little more than an early commentary on the impact of COVID-19 on the adult social care ‘system’. What is clear, however, is that COVID-19 thrust adult social care into public awareness and political consciousness in an unexpected and startling way, the longer-term consequences of which remain uncertain (Department of Health and Social Care, 2020f).

The narrative throughout this volume has been of a model of commissioning and provision that has been struggling, if not failing outright, and that could therefore easily be destabilised by any of its inherent weaknesses. Prior to 2020, the forces of destabilisation tended to be around funding shortfalls and a fragile provider market. COVID-19 constituted something very different: a colossal stress test of everything previously taken for granted about the economic, political and social order. The timing of the virus was unanticipated, the severity underestimated and the preparedness barely existent; adult social care was soon caught in its headlights.

The immediate response was around clinical matters – testing, tracing and tracking, the acquisition of personal protective equipment (PPE), and the curtailment of business activity and social interactions via lockdown. However, the pandemic also created some very specific challenges for adult social care and, in so doing, revealed much about the way the sector is perceived by politicians and policymakers. These challenges reflect many of the issues analysed in the preceding chapters, notably:

• • deficiencies in funding and administration

• • fragility of provision

• • low policy salience

• • unethical policy and practice

Deficiencies in funding and administration

Chapter 6 drew attention to the ad hoc ‘sticking plaster’ model of funding for local government and, by extension, adult social care – a confusing mix of modest sums to fix crisis-related problems, often distributed through NHS organisations and unrelated to any coherent strategy for the sector. The COVID-19 crisis witnessed a continuation of this approach; within the space of three months, no less than eight new pots of money were allocated from central government to ameliorate the impact of the pandemic on local government.

Introduction

Adult social care cannot be understood in isolation from its wider environment: it functions in accordance with legal requirements; it has, of necessity, relationships with other services, notably, the NHS; it is affected by the wider context of poverty and inequality; and it is shaped by political perceptions of its significance. However, like all policy domains, it requires two prerequisites to be in place: an adequate funding base and effective administrative capacity. Both have been missing in the case of adult social care.

Funding

Inadequate funding is at the heart of policy dilemmas in adult social care. It has two dimensions. First, there is the long-standing squeeze on local government expenditure by central government. This has had the effect of reducing access to services and support for those dependent upon publicly funded care (and other services) and prompting some providers to leave the market. Second, there is the long-running question of finding a long-term solution to the balance of funding responsibility for long-term care between the state, the individual and families.

Local government funding

Around 65 per cent of providers’ income comes from care arranged and funded by local authorities, so the level of council funding is essential to the maintenance of the sector (National Audit Office, 2018a). There is, however, no national budget allocation for social care; instead, it is funded through multiple sources, including both public and private funding. Core funding includes support from central government in the form of a revenue support grant (which is not ring-fenced) provided to local authorities, and additional income generated locally through council tax and business rates. Moreover, unlike the NHS, there is no arrangement for funding over multiple years. Planning and investing for the future is impossible when funding streams are left to annual political caprice.

The current policy is that the main plank of central government support (the revenue support grant) should cease by 2020. Local authorities will then having to rely on local business rates and local council tax but will be able to retain 75 per cent of business rates (up from 50 per cent) through the Business Rates Retention Scheme; the piloting of 100 per cent retention is expected in some parts of the country.

Introduction

As Chapter 8 noted, the advent of COVID-19 resulted in the creation of an official ethical framework for adult social care. However, even where ethical ideals are pronounced by government or expressed in organisational mission statements, it is unlikely that they will be much discussed in practice and turned into realistic measures to guide action. Indeed, the most common discussions about ethics tend to be of breaches of integrity, such as intimidation, discrimination, manipulation of information, breaking rules and conflicts of interest (Huberts, 2018). It is therefore important to be clear not only about what is understood by new ethical standards (see Chapters 7 and 8), but also how ethical behaviour can be more robustly incorporated into the way services (and indeed goods) can be delivered.

Instilling ethical behaviour

In England, the most notable attempt to address the place of ethics in public life was the creation of the Committee on Standards in Public Life (CSPL) by the then Prime Minister John Major in 1994. The task of the CSPL was ‘to examine current concerns about standards of conduct of all holders of public office, including arrangements relating to financial and commercial activities’. The CSPL went on to articulate seven principles of public life, now often referred to as the ‘Nolan Principles’: selflessness, integrity, objectivity, accountability, openness, honesty and leadership (Bew, 2015).

In 2014, the CSPL published a review of the application of these standards to the provision of public services (Committee on Standards in Public Life, 2014) and formed several conclusions: that the public wanted common ethical standards regardless of sector, supported by a code of conduct; that ‘how’ the service is delivered is as important to the public as ‘what’ is delivered, with a wish for personalisation and a user-led definition of quality; that public and stakeholder views of what should constitute ethical standards were broadly in line with the Nolan Principles; that commissioners expect providers to conform to ethical standards but rarely explicitly articulate this; and that commissioners themselves wanted guidance on how to embed ethical standards in the commissioning and procurement process.

Ethics and ethical care

In his classic work The Language of Morals, the philosopher R.M. Hare (1952) argued that a ‘moral statement’ is one that prescribes a course of action – it is recommending that something should be done rather than just expressing the feelings of the speaker. Ethics is therefore about how human beings should treat each other, and it covers matters of rights, responsibilities and well-being. However, ethics is not only about finding the right response to a given dilemma; it is also about justifying the decisions and choices made. According to well-established theories, actions can be judged as right or wrong according to either their consequences (as in utilitarian theories) or according to conformity to ethical rules or duties (as in deontological theory). A further position is ‘virtue ethics’, which holds that it is the character of the moral agent that matters – a good person performs good actions, which have been learned and acquired through experience, practice, role models and good examples (Rachels and Rachels, 2015).

Regardless of the theoretical stance, ethics has to be capable of application to practical situations. This was the Victorian tradition, for example, with Bentham's concern with prison reform and J.S. Mill's campaign for women's suffrage. More recently, the interest has focused on defining the place of ethical behaviour in professional responsibilities – about how people in professional roles ought to behave. Banks (2012), for example, identifies three clusters of complex values that should guide professional behaviour, all of them germane to adult social care:

• • respect for the dignity and worth of all human beings – respect each human being as an individual, treat all people as equally valuable and respect the right to self-determination;

• • promotion of welfare or well-being – the obligation to bring about benefits for service users and for society more generally; and

• • promotion of social justice – the obligation to remove damaging inequalities.

The literature on the ‘ethics of care’ focuses on the responsibilities inherent in situations where individuals are defined in terms of their relationships with others. For Held (2006), this involves valuing rather than rejecting emotion – sympathy, empathy, sensitivity and responsiveness are the sorts of emotions that need to be cultivated.

The institutional legacy

The adult social care services that are available today have evolved from the residual institutional provision that was made available to paupers of all ages under the Victorian Poor Law (Thane, 1996). Although the Poor Law was revoked to widespread acclaim by the National Assistance Act 1948, unlike other sectors (notably, health, housing and education), no comprehensive policy was introduced to replace it. The 1948 Act (Section 21) stated that it should be the duty of every local authority to set up a ‘welfare department’ to provide ‘residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them’. Section 28 further empowered local authorities ‘to promote the welfare of persons who were blind, deaf or dumb, and others who were substantially and permanently handicapped by illness, injury or congenital deformity’.

These obligations to offer institutional care constituted a clear reflection of Victorian policy solutions. It still remained ultra vires for local authorities to develop preventive services like meals-on-wheels, chiropody, laundry, visiting schemes or counselling – these were viewed as ‘extras’ and therefore the domain of the voluntary sector (Parker, 1965). Changes to this situation took place slowly. The National Assistance (Amendment) Act 1962 for the first time allowed local authorities to provide meal services directly, as opposed to making grants available to the third sector. The Health Services and Public Health Act 1968 further afforded councils a general power to promote the welfare of older people, while a private members bill introduced by Alf Morris MP resulted in the Chronically Sick and Disabled Persons Act 1970, which was designed to compel local authorities to develop comprehensive welfare and support services for disabled people (Means et al, 2002).

These powers to develop preventive services were not matched by the allocation of additional resources, leaving local authority welfare departments small and marginalised. Even the main remit of these departments – residential care – was not undertaken particularly well. In the case of older people, Townsend (1964) noted a lack of investment across all welfare institutions caring for older people. In 1949, 40,000 residents were housed in former workhouses, and by 1960, the figure was still 35,000.

Writing this book has been both a personal and an academic journey. The Local Authority Social Services Act 1970 created new powerful local authority social services committees to plan, develop and deliver what we now call ‘social care’ for children and adults. In 1972 I was elected as a young councillor in Sunderland and served on the newly created committee. At the time it was assumed what was termed ‘the personal social services’ would follow the path to ‘welfare state’ status that had already been taken for health, education, housing and social security. There was much to commend this short-lived era though it was not without its faults and critics.

Today even the term ‘social services’ has vanished and the policy landscape has changed beyond recognition. Local authorities no longer make long-term plans, neither do they deliver services and support – that is largely the province of private companies. In the process there has been a complex shift in the way that we think about those requiring support to live their lives – a mix of client, consumer and citizen. Whereas fifty years ago I was a member of a working group developing a ten-yearear plan for local authority service expansion, today I am hunting around ‘the market’ trying to find a suitable and affordable care home for a family member. Politics, policy and the personal eventually intersect for all of us.

The book is not a diatribe about one approach or another, neither does it identify any simple solution; rather it seeks to untangle a complex story, to identify shifts and strands, continuities and discontinuities, problems and options. Putting it together has been hugely helped by so many excellent staff at Policy Press; from the first pitching of the idea right through to the final proofs, the team has worked like a well-oiled machine. My thanks to you all. Thanks also to those organisations and authors who have kindly given me permission to directly quote their work, and to the many scholars and practitioners whose work I have admired, utilised and referenced. And finally, a massive thank you my wonderful wife Val who has encouraged me to write this book.

Introduction

There are clearly problems with the operation of a market in adult social care; what is less evident is how to respond to this situation. Logically, there are three options: retain and reform the market; replace the market with a state-run service along the lines of the 1970s’ model; and develop a new approach that is distinct from both of these options. This chapter is concerned with the first two options – put simply, state or market? Chapter 7 explores the scope for a third approach.

Renationalising the adult social care sector

As noted in Chapter 2, the outsourcing of public services to non-statutory providers, especially the private sector, has been the delivery model of choice in the UK for around 30 years. The budget devoted to such contracts is hard to estimate but is reckoned to be in excess of £100 billion (Walker and Tizard, 2018), equivalent to about 8 per cent of gross domestic product. The model has also changed in nature over the years, moving beyond back-office functions and into front-line service delivery.

A number of high-profile problems and outright failures have brought the limitations of this model into more prominent view. Perhaps the most spectacular was the collapse of the outsourcing giant Carillion, which managed services across education, the NHS, prison services and transport – indeed, 60 per cent of its work came from government contracts to deliver public services and facilities. The scathing inquiry by two joint committees of the House of Commons (House of Commons Business, Energy and Industrial Strategy Committee and Work and Pensions Committee, 2018) discovered not just incompetence, but ethical failings rooted in fecklessness, hubris and greed.

Concerns have also been raised across a number of other outsourced public services, including probation (HM Inspectorate of Probation, 2017; National Audit Office, 2019), the prison service (Dockley and Loader, 2016), the forensic science service (Commons Science and Technology Committee, 2016), the NHS (NHS Support Federation, 2017) and children's social care services (Jones, 2018). It is little wonder that in its inquiry into the wider issue of outsourcing and contracting, the Commons Public Administration and Constitutional Affairs Committee (2018) concluded that: it was unclear how and why the government decided whether to outsource a particular service; the evidence used to support outsourcing decisions was ‘thin or non-existent’; and there had been a depressing inability to learn from repeated mistakes.

The nature of commissioning and outsourcing

In broad terms, ‘commissioning’ refers to the process of the planning and strategic purchasing of services. While there are many models available, they all fundamentally break down into four key areas:

• • analysis: understanding the value and purpose of the agencies involved, the needs they must address, and the environment in which they operate;

• • planning: identifying the gaps between what is needed and what is available, then deciding how these gaps will be addressed;

• • doing: securing services and ensuring they are delivered as planned; and

• • reviewing: monitoring the impact of services and ensuring future commissioning activities take review findings into account.

The danger is that these complex activities are, in practice, reduced to a competitive tendering activity, often framed by a rigid set of costed outputs and complex contract conditions. As seen in Chapter 2, local authorities were required to radically shift their role from direct provision to commissioning. In so doing, they stepped into an unfamiliar world, one that is normally found in commercial business, such as sourcing providers, negotiating contracts and monitoring arrangements. The research conducted in the 1990s by Wistow et al (1994, 1996) revealed what a culture shock this was at the time for local councillors, officers and front-line staff, who were more accustomed to a traditional ‘welfare state’ model. It might be expected that since that time, there would be greater familiarity with the task and less resistance to the principle but this is not necessarily the case.

Today, around a third of all public expenditure is outsourced via ‘procurement’ (Pritchard and Lasko-Skinner, 2019) even though the record of achievement is, at best, mixed. The most spectacular recent failure was the collapse of the outsourcing giant Carillion, which had managed services across education, the NHS, prison services and transport. Other outsourced public services that have run into difficulty include the probation service, the prison service, rail franchising, the forensic science service, Learn Direct, court translation services, housing for asylum seekers, welfare benefit assessment, free schools and academies, and the NHS. Overall, evidence of successful outsourcing is remarkably thin on the ground.

If you want to know the exact date of an ancient object or structure, find an inscription. In the 11th–13th century Bagan period, stone inscriptions give the founding year of dozens of pagodas. Some inscriptions, motivated by an urge to commence building at an auspicious moment, go so far as to nominate the day, hour or even minute when construction began (see, for example, Luce 1932). From Bagan onward, these absolute dates have provided a vital chronological framework for historical and archaeological analysis. When monks and scholars sat down in King Bagyidaw's “Glass Palace” in 1829 to try to bring together the often contradictory narratives of earlier chronicles, pagoda histories and religious commentaries, they recognized the value of inscriptions for their dates as well as for their dedicatory content (Pe Maung Tin and Luce 1923).

A “scientific” date, generally from carbon, can also provide an accurate time for a past event, but the time is within a range of centuries, not a specific year. However, radiocarbon dates can also go back many thousands of years before inscriptions. So far there have been relatively few samples from Myanmar tested to provide carbon dates, but the results of carbon dating so far show, among other things, that construction and other economic and cultural activity was taking place between the 1st and 3rd centuries ce at Sriksetra, Halin and Beikthano (figure 6.1). These date ranges help provide a framework within which we can view changes in art styles, palaeography, architecture and expressions of religious ideas in text or sculpture during the early urban period, before inscriptions appear.

Radiocarbon Dating

Radiocarbon dates tell us when the material being tested was alive. The material is usually wood which, before it rotted away in the ground, was converted to charcoal by burning and was thus preserved. During its lifetime the wood took in an isotope, Carbon-14 (written as 14C).