Statutory social services were established in 1971 as the final
foundation stone of the welfare state. Their origins lay in the
1968 Seebohm Report, which recommended unifying the then separate
children's and welfare services.
The report's central philosophy was encapsulated in its call for "a
new local authority department, providing a community-based and
family-oriented service that will be available to all. This new
department will, we believe, reach far beyond the discovery and
rescue of casualties, it will enable the greatest possible number
of individuals to act reciprocally, giving and receiving service
for the well-being of the whole community."
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Elsewhere, the report advocated integrated care, community
involvement, citizen's participation, consumer choice and the
development of community identity - all themes with a remarkably
contemporary echo in a modern policy context that aspires to social
inclusion, community capacity building, social cohesion and
democratic renewal.
However, social services have tended to focus on the symptoms of
social exclusion, reinforcing perceptions that consumers of social
care are social casualties rather than citizens with particular
needs. Middle class "buy in" to social care as a universal service
has been difficult to secure and sustain.
However, the 1998 white paper Modernising Social Services
emphasised that "social services are for all of us". Breakdowns in
services have "damaging consequences" for other people as well as
the individual. Moreover, it said that "all of us are likely at
some point in our lives to need to turn to social services for
support, whether on our own behalf or for a family member". Social
services were part of "the fabric of a caring society", not merely
the supporter of "a small number of social casualties".
This emphasis on high quality services, firmly focused on the whole
community, is a starting point for future policy objectives.
However, we need to be clear about the outcomes social care is
intended to achieve. The limitations of a narrow, individualistic
philosophy are, perhaps, nowhere more apparent than in social care.
Our well-being is affected by the quantity and quality of our
personal relationships, as well as other features of our social,
economic and physical environments.
Desired outcomes for individuals have been associated with enabling
them to maximise their abilities and opportunities for
decision-making and independent living. Since the 1989 Caring for
People white paper, which led to the NHS and Community Care Act
1990, these desired outcomes have tended to be expressed through
the mantra "choice and independence". But neither of these is
sufficiently well-founded or evidence-based to shape the future of
social care in the 21st century.
Definitions of independent living as "maintaining people in their
own home for as long as possible" need to take into account the
necessity for engagement with others. The ability of individuals to
maintain and regain their independence appears to be related to the
quality and quantity of family and social networks and providers of
emotional and practical
support.
1 A study of
older people recovering from fractured neck of femurs found that
they believed their own motivation and help from family and friends
was more important in their ability to regain health and confidence
than professional help. Informal support was also found to be an
important factor determining which individuals returned home rather
than entering institutional
care.
2
The concept of a "safe discharge" similarly illustrates the link
between individual and collective outcomes: a clinically safe
discharge implies that individuals should not be placed at risk
through the absence of clinical or support services. From an
individual and family perspective, however, it extends to whether
there is a safe home and community in which to regain confidence
and physical independence.
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Choice is similarly flawed and limited as a central outcome. First,
some users of social care services do not voluntarily choose to
access them. Second, the very conditions that give rise to the need
for services may militate against choice (for example, frailty,
confusion, mental health problems, personal and family crisis, or
the breakdown of caring relationships). Third, decisions about
access to social care are generally rare lifetime events and we
have little previous experience to guide or inform our choice.
Finally, the concept of choice is inherently flawed if there are
too few options.
All these considerations suggest that future objectives should not
only be based on some of the most fundamental historic values of
social care but must also be re-cast to take account of more recent
evidence and understanding. In particular, choice and independence
need to be re-formulated in terms of access to real options,
personal empowerment, inter-dependence and inclusion.
Current policy is focusing considerably more attention on social
exclusion and social cohesion. Perhaps for the first time, social
care has a real opportunity to work with the grain of public
policy. The most important outcome for the next two decades must be
to narrow the gap between intention and reality. Achieving it,
however, will require a different balance between high-minded
rhetoric and the grind of day-to-day implementation than either
central or local agencies have yet secured. But the prize is huge
in terms of the well-being of individuals and communities.
Gerald Wistow is director of the Nuffield Institute for
Health, University of Leeds.
References
1 M Godfrey and T
Randall, Communities that Care: Developing a Framework of Risk
Assessment and Prevention Approaches Relevant to Older People,
Nuffield Institute for Health, 2002
2 G Herbert et al,
Rehabilitation Pathways for Older People after Fractured Neck of
Femur, Nuffield Institute for Health, 2002
The big debate:
The report of the New Visions project - From Welfare to
Wellbeing: the Future of Social Care - will be published on 17
October and launched at the National Social Services Conference in
Cardiff. The project was commissioned from the Institute for Public
Policy Research by the Association of Directors of Social Services
and Community Care.
Community Care is publishing a series of articles based on the
chapters of the report, to engage the social care workforce in a
debate about future services.
The series continues as follows:
3 October. Liam Hughes, chief executive, East Leeds Primary Care
Trust: The Future Workforce of Social Care.
10 October. Anne Davies, independent policy analyst: Structures
and Accountability for the Future of Social Care.
17 October. Liz Kendall, associate director, IPPR:
Conclusions
