Can’t see the wood…

To the outside observer, the to-ings and fro-ings of social care
debates must seem, at best, bewildering and, at worst,
contradictory. Given the range of perspectives, roles and interests
of all those involved in social care, it is, perhaps, unsurprising
that there should be differences in understanding of what
“improving services” entails, and how best to achieve it. For those
obliged to spend their time working with the nuts and bolts it can
be hard to find time to stand back and take in the whole social
care machine, or to pontificate about its broader purpose.

Yet there is an urgent need to develop a shared vision that goes
beyond the level of soundbite. For example, we probably believe
that poverty should be eradicated, equality and social inclusion
promoted and independence facilitated. But what does this actually
mean? Having worked it out, it might become clearer what role
community care can play and what policies and structures are
required to maximise its efficacy.

The aim of the London NHS Region’s Older People’s Development
Programme is to promote independence through delivering
person-centred, co-ordinated services. The strategy focuses on
collaboration across a multitude of health and social care
agencies. Objectives cover the identification of vulnerable older
people in the community, initiation of the single assessment
procedure, delivery of co-ordinated services and gathering the
views of older people. At one level, this all seems clear. But, in
some ways it only represents the tip of an iceberg – the
conclusions of several interesting debates. These may well have
occurred, but to the outside observer they are not visible above
the waterline.

To begin with, what is understood by “independence”? For some
service users, the independence they seek in the first instance is
from the intrusions of statutory and other agencies. Yet what is
striking here is the number and variety of agencies that are
involved in the development programme, and thus, potentially, in
the lives of older Londoners. Indeed, the independent living
movement defines independence not in terms of living by yourself,
or doing everything for yourself, but as having access to the
support you need in ways you choose.¹

Alternatively, “independence” may simply be taken as shorthand for
“in the community” rather than in residential care. Yet, in theory,
independence may go alongside isolation, and being in the community
is certainly no guarantee of independence.

It seems sensible to design services to reflect the fact that
people are multi-faceted, as can be their needs – and to minimise
the need for repeatedly collecting the same information. However,
the disability movement has long sought to “demedicalise”
disability, making the valid point that ill-health and disability
should not be conflated or confused. Meanwhile, the introduction in
Scotland of free personal care for older people makes it necessary
to categorise forms of assistance – so was the bath for health,
social or personal reasons?

If it makes sense to bring together different types of services
around a given client group, does it also make sense to bring
together client groups? What, other than resource limitations, is
the rationale for having free personal care for older but not for
younger people, or for personal but not social care? If the
approach of the development programme works in London, why not
mainstream it more widely? Could the exchange of good practice and
innovation usefully be extended, both geographically and across
client groups?

Improving the interface between services, and even merging
services, may well improve coherence. It would help, too, if policy
was similarly coherent. One size cannot always be expected to fit
all, although it is not always evident why it should not be
designed to accommodate greater diversity.

However, it cannot be guaranteed that throwing different
ingredients into the same pot will automatically cause them to
blend into something palatable. Although it may seem simpler, it
may turn out to be more complex and bureaucratic. The pursuit of
the holy grail of the perfect structure for services can spawn
multi-headed, multi-bodied monsters, with legs apparently marching
in all directions. Without articulating shared, in-depth
understandings of what it is all for, of where simplicity is
possible or complexity necessary, the outside observer – and
perhaps sometimes the internal participant – seems likely to remain
none the wiser.

¹F Hasler, J Campbell, G Zarb, Direct Routes
to Independence, Policy Studies Institute & National
Centre for Independent Living, 1999

Sally Witcher is a freelance consultant and researcher. She
was formerly director of the Child Poverty Action Group.