CARE MATTERS: ‘Social Care in the UK’s Four Nations’ with Catherine Needham and Patrick Hall

Episode transcript

The Care Matters podcast is brought to you by the ESRC Centre for Care and CIRCLE, the Centre for International Research on Care, Labour and Equalities. In this series, our researchers welcome experts in the field and those giving or receiving care to discuss crucial issues in social care as we collectively attempt to make a positive difference to how care is experienced and provided.

Dan Williamson

Hello and welcome to this episode of the Care Matters Podcast. I'm Don Williamson. I'm the producer of the podcast and the digital and communications coordinator for the ESRC Centre for Care and CIRCLE. For today's episode, I am pleased to be joined by two colleagues whom I've worked with for a number of years, starting during the ESRC-funded Sustainable Care program, which ran from 2017 to 2021, and they've authored a book detailing research and findings carried out during the program, entitled ‘Social Care and the UK's Four Nations Between Two Paradigms’.

And this is what we've come together today to discuss. Catherine Needham is professor of Public Policy and Public Management at the Health Services Management Centre at the University of Birmingham. Her research focuses on social care, including personal isolation, co-production, personal budgets and care markets. She's published a wide range of articles, chapters and books for academic and practitioner audiences. Katherine led the care in the Four Nations work package within the ESRC Sustainable Care Team. She's now leading research on care systems as part of the ESRC Centre for Care and is also a member of IMPACT, The UK Centre for Evidence Implementation in Adult Social Care. Welcome, Catherine.

Catherine Needham

Thanks, Dan

Dan Williamson

And we also have with us today Patrick Hall. Patrick is a social care policy researcher currently undertaking an ESRC-funded PhD at the University of Birmingham on care commissioning. He was the main researcher on the care in the Four Nations work package within the SC Sustainable Care Team. Prior to that, he contributed to the European Commission's 2018 peer review of Germany's latest long term care reforms.

Patrick is a former fellow of the King's Fund, where he co-authored two publications on social care for older people. Before The King's Fund, he worked with the Department of Health and Social Care. Local authorities and NHS organisations on the implementation of the CARE Act 2014. Hi Patrick.

Patrick Hall

Her Dan. How are you?

Dan Williamson

Fine, thank you very much. It's nice to see you

Patrick Hall

A very good introduction.

Dan Williamson

It's was a long one! We got there in the end. So as I mentioned earlier, we've come together to talk about your new book entitled Social Care and the UK's Four Nations: between Two Paradigms. So what is social care reform trying to achieve in all four nations?

Catherine Needham

So the focus of the book is on England, Scotland, Wales and Northern Ireland. And we're really looking at the period since 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 really quite different care systems in the UK.

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 that there 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 nations and some of the people 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 were and what some of the learning would be.

So in terms of kind of what they're trying to achieve that we would say that in all four of the nations is a sense that care is in crisis, 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 sense that the systems and services that we've got in place were created for a kind of post-war 1945 population that really doesn't reflect the kind of current populations.

So we've kind of conceptualised this in terms of five care crises, which all of which are responding to a crisis of demand. So a sense that because of population ageing and demographic change, there is now this some strain on care systems. And in response to that we've kind of we could talk about a crisis of families. So assumptions that were made about the distribution of care within families have changed.

Families, though, continued alongside other unpaid carers to make an enormous contribution and be hugely in strain and in need of increased support. So we think there's a sort of a crisis there around the role of the family. We could say there's a crisis around the role of the state, you know, the state in that kind of post-war era.

But lots of institutions put things in place to support people, but those were not always supports, which really allowed people to lead good 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 what we call the crisis of the market, lots of, you know, huge proliferation of care providers, some of whom are kind of delivering poor quality care on stable financial models.

So we can see that there's a problem around the market. And then the last of all kind of crises is around community, a sense that we're all kind of very keen on the development of not for profit providers of natural community resources in people's neighbourhoods and lives that will allow them to, you know, move away from that sense of kind of isolation and loneliness and kind of leading good flourishing lives with a sense of purpose and meaning, which is really what I think all of us would want from life.

But actually there's lots of reasons why community is also under strain and the kind of spaces and places that people maybe went to used to go to get that support are disappearing. So in response to that, we then in the nations say that we think that care policy is trying to achieve a number of things and 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 individual and collective wellbeing. There's a real language about fairness and 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 mean that you ought to get free care services?

And that's not the case at the moment because that means tested. So there's a lot of discussion around fairness. Rights is another key to narrative around the sort of human rights focus around social capital in Scotland. That language is used very much around rights and entitlements. There's something around equality, and I think that raises big questions. Quality for whom are we talking about?

Quality care services for people in families receiving care, or are we talking about quality work, quality jobs? Because those things about pulling in different directions? And then finally, it's about sustainability. Can this all add up together to a system that meets fairness of rights and wellbeing to a set of arrangements which is sustainable for the long term and actually meet the kind of the demands that potentially be in place.

Patrick Hall

Yeah, so there are kind of a number of different ways in which policymakers and legislators have tried to respond in these areas, and we identified six different areas or mechanisms whereby they try to achieve wellbeing, fairness, rights, good quality care and sustainability. And so those areas are around redistributing costs. So that's particularly in response to this idea that the system's unfair somehow, that, you know, you could have saved up all your life, you could have worked very hard to, you know, buy a house and then, you know, all of a sudden it disappears very quickly.

You know, if you had to move into a care home and personalising support. So this idea, the you know, the state institutions are often, you know, poorly equipped to respond to the needs of individuals. And actually a kind of a diverse range of provisions should be responded to very particular needs of both individuals, communities and across different kind of what might be called client groups in social care.

Make working age adults, people with mental health problems and older adults supporting carers. So this this speaks to that idea that 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 doing too much, in that they can't, they can't meet the needs of their, but they're also perhaps doing too little so that they aren't, you know, they aren't supported to do the care that they perhaps could do investing in prevention.

So, you know, that's a big part of the narrative across the four nations. So intervening earlier in order to prevent people 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 experience a lot more. Joined up when people have to deal with both the NHS and the health system and with the social care system, which is the case for, you know, a large proportion of people that go into hospital or often have to try and get a package sorted 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, 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 lot in all four nations which try these trying to to push for a more professionalised workforce. And so that might include things like workforce regulation 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, supporting carers, inventing them, investing in prevention, integrating with health professionals in the work that we're doing in order to kind of serve the principles of wellbeing, fairness, rights, quality and sustainability.

Dan Williamson

First, thank you for that was really good. So this book presents for the first time research on the perspectives of social care policymakers on the four systems in which they operate and the ways in which they can borrow from one or the other. But which of the foundations has made the most progress on social care reform?

Catherine Needham

So as you can imagine, it's a kind of it's a it's an it depends kind of answer, because there's a number of different ways of looking at it. But I mean, one of the ways you could look at it is sort of who's gone furthest around some of these key areas that 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 ways Scotland is the furthest advanced, at least in terms of its kind of what's going on, those on the statute books and the kind of legislation. So there's obviously issues around implementation and that's very difficult and awful. But one of the things that we would say is 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 hard to make progress on care reform. And I think we've said that on the whole, Scotland has had no, you know, the most advantageous. 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 smaller nations like Wales or Northern Ireland.

Scotland had a lot more institutional stability. It hasn't had the kind of institution building that Wales has had to do because Wales had a quite kind of anaemic devolution settlement. It's really had to kind of build on. And then in Northern Ireland you've had just long periods of suspension of the executive and and real difficulty making getting off the starting blocks in terms of care legislation.

So what they've managed is Scotland, which we think is probably one of the reasons that they've advanced so far, is have this kind of iterative approach rather than having a big set piece act like the CARE Act in England or the Social Services Lobbying Act in Wales, that kind of built up slowly with the free personal care coming in around 2002, they've had the Self-Directed Support Act and then they kind of built up the legislation over time.

And I think we would consider that that's been quite advantageous because it's meant that some of the people who might oppose certain elements of reform haven't had this big target to aim at. And so I think we think that there's some advantage really in this sort of incremental approach to reform that's going further in Scotland.

Patrick Hall

It's kind of understanding the social care system as a system rather than just as a kind of, you know, problem to be solved. You know, that's that's one of the the main messages of the book is that part of understanding social care is it as a complex system is, you know, is one of the most important things when we're thinking about, you know, building a more sustainable approach to reform.

And so, you know, there are lots of problems. It is difficult kind of responding to 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 most put the most kind of policy attention 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 people who are able to access that much more kind of personalised support has kind of really stalled in Scotland in some ways. So, you know, maybe a younger, disabled person who's looking for that much more flexible support might say, well, actually Scotland hasn't got as far as England in some ways.

So, you know, it's it's always difficult responding to those questions about, you know, who's best who, you know, it's like, you know, who's is best for who, You know, because the social care system so diverse and the needs of a younger, disabled person and perhaps an older person who's frail, kind of going in and out of hospital, also fundamentally different that, you know, that question could be answered for each of those people in different ways.

Dan Williamson

Just a spin off question, I suppose. Is there any particular learning from Scotland that the other four nations could take on right now and run with?

Catherine Needham

Space is quite interesting seeing what's happening in Scotland with the National Care Service, which at the moment is paused the reforms with the change in First Minister. And so it's kind of one of the things we we've been talking about is whether kind of Scotland has got itself a bit unstuck because it's now trying to do what all of the other nations have done, which is to sort of have this big set piece of legislation where which kind of you just end up maximising the target for the central veto players.

And so you've got this kind of coalition of, you know, local government. I like it. The GP's are like the trade unions don't like it, you know, the family courts at one point we're going to be involved and they didn't like it. So there's, you know, you kind of suddenly everybody saying the reason why that can't happen and you get this momentum around it.

So I think, you know, the learning perhaps from the other nations and Morrissey from Scotland is that incrementalism may be a better way to go rather than, you know, we've got this sort of like fixed social care for generations, you know, fix it once and for all type language from politicians. And maybe that isn't the best way to do it.

But, you know, incrementalism also is it's risks because, you know, you get you know, one of the one of the issues which we found is that each successive piece of legislation starts to draw attention away from what went before. So, you know, you kind of suddenly you're over here looking at integration with health and you forgotten that you actually passed a bill about solidarity support like two years ago in Nice because suddenly things have moved on.

So, yeah, there's no easy answer, I think.

Patrick Hall

No, I think that's right. And I think we probably strike a 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's just that, you know, the guys of those veto players can be different in different contexts. You know, obviously in in the Westminster system, 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, stifle something right at the end of a process and kind of just say, well, there just isn't the money for that to happen, you know, where that kind of siloed style where you get in Westminster is absent. We kind of in some ways you'd assume that there wouldn't be that kind of veto player dynamic. But actually, you know, we can see that with the kind of going for this big bad National care Service that kind of created an opportunity for different types of veto players, you know, different people within the system.

It's been interesting kind of see the response from local government, you know, and and from others, particularly the 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 follow through on the promises that, you know, I think when you when you're when you're doing something which is a little bit more iterative, kind of focusing on different parts of the system, then that target isn't quite so big.

Dan Williamson

So I think we're, we're starts to build a better picture of why social care reform is so hard. But is there anything you'd like to add about why it's so difficult?

Catherine Needham

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 leaders willing to spend on social care because we've just had this repeated pattern in England of kind of politicians say they're going to sort it.

They pass a piece of legislation which, you know, something like the cap, cap, you know, has been passed into primary legislation twice now. And nonetheless, you know, it's now looking very unlikely that it's ever going to happen. And partly that's because, you know, the costs we know that if we'd had the natural slavery, you know, it would have been cut upfront costs on certain benefits for a few people down the line.

And so politicians are not willing, I think, to expand the right amount of political capital on it and have the kind of political courage that it takes. So it's something about changing, I think the whole public debate around it, making it, you know, trying to raise its profile, visiting the NHS, which obviously does have a much higher political profile and public support, and are the first people to think about how that might be done. But yeah, it is a tricky one.

Patrick Hall

I mean, it's one of those areas which 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, gravestones and all of this sort of thing. Is that that's part of the reason why it's so difficult, you know, to do to kind of there are lots of kind of psychological reasons why, you know, dealing with social care isn't an attractive prospect for politicians.


It's not kind of, you know, a positive and sexy sort of, you know, future future looking is about sustainability, about the kind of society that we want to live in. It's difficult, you know, it's very 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 want to say is that, you know, social care reform is is as much about kind of trying to anticipate some of those potential institutional barriers to reform before you even think about what the vision for for a social care future is.

Dan Williamson

Well, thank you for that. So let's talk about the overall contribution of the book so policymakers can decide between two paradigms. Do they want care to be more standardised, regulated, formulas centralised, or do they want it to be more differentiated though more informal and personalised?

Patrick Hall

Yeah. So that's the you know, is the kind of the conclusion of the book is that, you know, when we're speaking to policymakers is that they tend to, when they're talking about a vision for social care, refer to a kind of a one kind of coherent vision for another. And those two visions kind of come together as what we call differentiated and 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 with very small packages which 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 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 pursue a very, very personalised system, then perhaps, you know, kind of regulating care workers wouldn't be the way to go. And I think what we see is in the policy documents is a combination of these two paradigms, you know, and they sit together without recognising some of the tensions between them.

And I think that's what, what we'd like to see in all of the systems is, is some kind of process for negotiating between these these tensions. So thinking about them in an open way.

Dan Williamson

Great. Thank you. Are there any other recommendations for policymakers that you like to emphasise based on the findings in the book?

Catherine Needham

I mean, I think, you know, we're lucky key contributions is to say let's sort of face these two paradigms explicitly and rather than trying to sort of pretend we can have the best of both worlds, say, well, maybe we have to make some choices or some trade offs and prioritise one way of doing things over another. So there's a really interesting exchange in the Scottish Parliament where Watson from Glasgow University asks Derek Feeney, who'd written the fair, the report which preceded the National Care Service proposals.

He so said, You know, subversive is what we found in the other nations. This idea of kind of, you know, there's two things running through the 50 report. One is about co-production personalisation, the others about kind of regulation and safety and consistency and, you know, they don't seem to fit together very well. And, you know, Derek Feely said have responded 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 conversations here needs to be about, you know, in what's the scale, first of all, of do 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 will need 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 about what do people get to choose in terms of how they spend their days, are they supported?

Let's make that as little as possible. But yeah, let's at least try and be explicit about the fact that there are tensions here and we need to kind of make sure we've got the right people as 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 conversation about what should be prioritised.

And often when you speak to people about that, some of the stuff around safety and consistency isn't necessarily people's top priority because, you know, good social care is about flourishing lives, it's about 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 know that people institute in institutions is almost never the way to achieve any of those things. So I think we say that, well, let's try and move away from, you know, assuming that kind of consistency is good in its own right and safety is almost always the most important thing.

Patrick Hall

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, for a differentiate, differentiate paradigm, you know, there are risks involved in terms of kind of safety and about kind of inconsistency and things like that. And there are dangers with a more standardised, 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 it's about recognising that actually these are kind of two different visions which exist at the same time in tension with one another.


And they are and they're often reflective of different interests, you know, the kind of interests of a frail 95 year old kind of going in and out of hospital, you know, would be one thing which might involve, you know, a much safer, much smoother institutional transitions, things like that, much more professionalised workforce around them. They might be served much better by that kind 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. 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 recognise that sometimes instead of being one, you know, we've only got limited resources and we don't serve another community. And that that needs to be a negotiated process whereby we think about where resources go in the system.

Catherine Needham

You know, and I think as well, you know, I guess because there has been a poverty of expectations around what older people can expect, we say, you know, old people want to go out with their mates as well. Let's make that happen now.

Patrick Hall

You're right. You're right. Yeah. I mean, it's yeah, that's I mean, that again, that's that's the whole type of conversation that needs to be had. You know, it's like actually, you know, those who advocate on behalf of older people want, you know, swing towards a standardised paradigm, but actually maybe they're making a mistake in doing that. You know, maybe that isn't what all of the people don't really want.

But, you know, I think it's about, yeah, having that conversation in a kind of a democratic setting, you know, which is kind of more iterative and deliberative than this idea of kind of doing things, fixing everything through a kind of one off big bang piece of legislation. And I thought we think is kind of both a mistake in terms of the narrative of it, but also the kind of yeah, the task as well always is misguided because it's kind of bound to fail because of some of these institutional barriers.

Dan Williamson

Well thank you before we wrap up, I think our viewers will be now very interested to know more about the book and whether they can get hold of a copy.

Catherine Needham

Yes. So it's available on the policy Press website. There's a hardback and an e-book and there's two other chapters are available, Open Access, which you can just get from the Post press website. So and we picked two chapters that we think some kind of nice parts of the book. So one of them, chapter four, is about our key findings, which are the foundations.

And then Chapter seven is about this notion of the two paradigms and how they come together and the intention and how we might move on from them. So yes, so people might want to just dip into those open access chapters or there's the option to get.