Modernising adult care

THE RESEARCH

Title: Modernising Adult Social Care – What’s Working?
Authors: Janet Newman is professor of social policy at the Open University Michael Hughes is director of studies at the Audit Commission
Institutions: Open University and the Audit Commission

ABSTRACT

This report pulls together the findings of nine research reports under the Modernising Adult Social Care (MASC) programme funded by the Department of Health, along with findings from two baseline studies. The research was conducted between 2003 and 2007. The aims of the report are twofold: to describe the findings of each of the separate reports and, more importantly, to pull all the findings together to assess progress and outcomes in the modernisation agenda. In doing so, the report develops a model for understanding the modernisation of social care based on the 7S model popularised by management consultancy the McKinsey Company.

OBJECTIVES

The main task in this report is to pull together four years’ work by more than 50 researchers all working on projects funded under the Modernising Adult Social Care initiative.

There are remarkable similarities between the challenges identified in the 1989 white paper, Caring for People, and the more recent policy frameworks set out in Independence, Wellbeing and Choice, and Our Health, Our Care, Our Say. This implies the existence of some implementation problems – why is it proving so difficult to put policies into practice? Trying to understand this “implementation gap” is the main objective of this report.

FINDINGS

The report draws on the findings from nine studies funded directly under the MASC programme, each of which is also separately available. The studies cover:

● The implementation of direct payments.
● The effectiveness of the National Strategy for Carers.
● Fair Access to Care (FACS).
● Health Act flexibilities.
● The protection of vulnerable adults.
● Electronic service delivery for older people.
● User and carer definitions of partnership.
● Partnership and regulation in adult protection.
● Smarter working in social care and health.

The findings from two baseline studies are also used: social care services before the influence of modernisation, and regulation and inspection. This amounts to a substantial body of research.

The difficult task facing the authors of the report (both of whom served as scientific advisers to the MASC programme) is to put this rich seam of research into a coherent analytical framework. They do this by using a 7S model with the following components – steering, standards, systems, staff and skills, style, synergies and super-ordinate goals. These are sub-divided into transactional processes that aim to produce compliance and deliver results (steering, standards and systems) and transformational pro­cesses that produce commitment and deliver outcomes (staff and skills, style and synergies). The final “S” – the super-ordinate goal of independence, well-being and choice – should provide the cultural glue that binds together these processes.

Using this model, the report pulls out a range of messages from the MASC projects. The key one concerns the complexity of securing change. Many of the individual reports highlight tensions not only between different national policy goals, but also between different priorities within the social care agenda itself. This can lead to a tricky implementation stage characterised by instability and disjuncture, rather than equilibrium and stability. Among the key findings are:

Central funding and targeting: Proper funding to secure change is essential and, where this was available, implementation was more effective. In areas where change was unfunded, such as FACS and the regulation of protection, implementation was more difficult.

Problematic role of the NHS: The projects often reveal a lack of clarity and knowledge about NHS roles in modern adult social care. This is not just about funding responsibilities but about professional cultures, with health staff routinely unfamiliar with social care perspectives and procedures.

Benefits and limitations of partnership working: Where there is effective partnership working between health and social care it does deliver the outcomes that users want, but too often partnership with the NHS can produce a marginalisation of social care perspectives within a health paradigm. The policy focus on solving problems in the acute health sector is seen as being at the expense of a productive policy focus on social care.

Staffing and leadership: Findings consistently highlight the importance of staff as the key mobilisers of change (transformational change), but the requirement to meet centrally imposed targets has created an instrumental climate (transactional change) in which questions of staff development and cultural change are sidelined.

Tension between competing social care agendas: The studies reveal tensions between the drive for consistency and the need to ensure flexibility, for example between direct payments and policies on the protection of vulnerable adults and FACS. The subsequent, more radical, agenda on personalisation represented by individual budgets and the In Control model will exacerbate these tensions.

Complexity of the policy process: Effective policy implementation depends on a range of factors rather than a single policy edict. Although government will set the rules of the game, it is local actors who will interpret and translate them for local circumstances, often producing different results in different contexts.

ANALYSIS

The findings of these research projects should provide rich pickings for understanding the answers to a set of key questions – what works in what circumstances, and what are the critical factors that make it work? Nevertheless some reservations about the MASC research programme can be raised:

Coherence of the programme: Programme funders are limited by the nature of the bids received, but it is doubtful that the nine projects could be said to add up to a comprehensive testing of any hypothesis about modernisation. Of course this may in part be attributed to the vagueness of the concept itself – as the authors note, the successive policy reforms relating to social care may not have been intended as a coherent programme of modernisation.

Value of the findings: Some of the findings from the individual reports are unremarkable, often appearing to add little to what is already known. Additionally, such medium-term investigations into a dynamic policy field will inevitably have a somewhat dated look by the time they see the light of day. Although the integrity of the work may still be intact, its usefulness to policymakers and practitioners is accordingly diminished. The authors concede that the adult social care agenda looks quite different in 2007 from that set out in the first stage of modernisation laid out in the 1998 white paper, Modernising Social Services. In particular the notion of independence has moved on markedly since the MASC programme.

Given these limitations, the authors have done an excellent job in imposing some retrospective coherence through the use of their 7S framework, and for those concerned with policy analysis the report is worth reading for this contribution alone. The report also goes on to outline a future research agenda in adult social care that promises more coherence than the projects funded under MASC, and lays down some vital challenges for the relationship between research and policy in social care.

Bob Hudson is visiting professor of partnership studies at the school of applied social sciences, University of Durham

LINKS AND RESOURCES

● Modernising Adult Social Care – What’s Working? can be downloaded from the Department of Health website
● Each of the nine studies funded under the MASC programme has produced its own list of findings. These are summarised in Executive Summaries and Policy Briefings and can be found on the MASC website
● The broader issue of integrating theory and practice in public management is the subject of the current issue of Public Money and Management, a bi-monthly publication by Blackwell.

PRACTICE IMPLICATIONS

All the projects funded under the MASC programme have a direct relevance for several levels of practice – policymaking, managing and front-line professional practice. The report identifies six key questions that need to be addressed in a future research agenda, each of which goes to the heart of professional practice:

● What are the cost implications of the move towards greater independence?
● How are the tensions between resources, needs and choices played out in the assessment processes in relation to different service user groups?
● How far can well-being be promoted by shifting resources to preventive measures?
● What are the impact of perceptions of risk on the capacity of the system to move towards independence and choice?
● How do individuals use support systems in exercising choice and maximising their independence?
● What are the implications of the moves towards direct payments and individual budgets for carers?

The constituencies of research, policy and practice do not constitute easy bedfellows, and it is evident from this report – as well as from elsewhere – that we have not yet got this relationship right. Notwithstanding some drawbacks, this is precisely the sort of report that needs to be shared and debated across the various constituencies if we are ever to grasp a better understanding of how to develop effective policymaking and implementation.

This article appeared in the 4 October issue under the headline “Modernising adult care”