Debating a Transparent British ‘carescape’ for health and social care reform

A story about British Social Care…. I recently shadowed a community nurse. I watched as she worked to enable a man with only one  week left of his life to be carried from his bedroom to a downstairs living room where on the TV was  football – his joy.   It took three hours of searching for her to find the assistance she needed, until  finally, an ambulance crew volunteered to help after their shift was over, to make the man’s hope come true. They were thanked with a large tin of biscuits funded by the community nurse herself.

Talk of British health and social care reform and renewal has been rife in recent months. Brexit has ‘got done’ and we believed that care would be next. Much of the media analysis however has often been confused: ‘health’ is referred to in the same breath as ‘social care’, which in turn can be blended with ‘nursing homes. ‘Carers’ can be clapped outside our houses: these include  ‘carers’ as paid public sector health workers in the NHS, lower paid social care staff in private and local government  providers, volunteers who have come forward during the pandemic, and the seven million unpaid informal or family carers who slog on, night after night, lifting and worrying and feeding and fetching for the person or people they support.

Better analysis and more creative and innovative thinking are needed if these confused silos are to be recombined by public leaders to create better public value.  Analysis needs to develop a sophisticated mobilisation of the whole ‘carescape’ upon which citizens might be able to draw, and state and society resource.

The notion of ‘carescape’ emerges from the work of sociologist and anthropologist Arjun Appadurai. In assessing emergent globalisation Appadurai teases out a variety of ‘scapes’ that are now shaping culture and societies taking in ideas, economy, technology, ethnicity, and media.

In their edited collection on ageing in sub–Saharan Africa, Hoffman and colleagues brilliantly apply a dimension of this approach to describe the ‘carescapes’ of African contexts. One cannot,  for example, assume safety nets of social protection policies in contexts where the state is weak, has an urban bias or has been captured at the local level by ‘strong men’ distorting policy that looked good when it left the capital.

Such a  mapping of a ‘carescape’ across the institutions and relationships that make up societies can also help us uncover more quickly than some approaches,  the role of extra-local or global forces in shaping provision or resilience whether that be the role of diaspora remittances in keeping care afloat – or the growing role of international health and social care providers and venture capital seeking private value from mutual aid.

The future advantage of working up a British notion of ‘carescape’ to underpin social care and health renewal then is that it might better help an understanding of existing sources of care and point to gaps and opportunities and risks.  It could ground a common civic conversation in which all the moving parts of social solidarity and exclusion are mapped transparently.

Indeed, instead of reaching for a mass produced welfare state or an idealised open market with a fixed ‘third sector’, ‘carescape’ forces us to pay deeper attention to the role of system and society.  These include the institutions of ‘care’ in the UK include unpaid carers and families; multi -generational families co-located and intentional communities bridging age and disability; commercial  investors in social care.  And also local authorities whose policy choices are as dramatically divergent as the huge realm of charities, firms, community centres and voluntary actors  that make up the realm of other spaces and places which people look for help or self-reliance.

Beginning this mapping can surprise. For example, in one survey, just before the C19 pandemic, I found that in some UK neighbourhoods a day spent by a frail older person at the local Wetherspoons pub was more cost effective, warmer, and likely to provide “more interesting company” across the day than some local day care and all local lunch clubs. Meanwhile, the everyday life of government and social care provision in another locality surveyed uncovered a waiting list for the waiting list to get on the formal waiting list for Adult Mental Health services. Here also were domiciliary care staff facing personal cash flow crises that literally left them without petrol to visit clients, and community nurses funding up to £1000 of parking fines a year because parking permits to exempt them were being issued too slowly or even being resisted.

Let us return to the story of the nurse, a dying man, and football. Unpacking the British ‘carescape’ is about a more nuanced approach to policy design that goes out of its way to offer a portfolio of interventions and allocations.

If multi-generational households drive down care cost and increase well-being how do tax codes move to affirm those who can evidence that they have chosen to live that way?

If some citizens volunteer as advocates, carers, befrienders above and beyond the social norm might they be entitled to the council tax reliefs that some authorities currently reserve for volunteer Special Constables in the police force?

As proposed health reforms to establish ‘Integrated Care Systems’ move  to large scale on footprints entirely out of kilter with smaller local government footprints how are the voices of minority groups, the most stretched carers and those with dementia heard, protected and resourced.

This term at the Institute we are exploring aspects of what one might include a ‘carescape’ from several directions in our Thursday seminars. Professor Martin Knapp will look at how economics might help us better understand dementia, Professor Jim Mcmanus the links between renewal and public health and Professor Mark Exworthy the potential or otherwise of a new NHS entrepreneurialism. From Ireland Professor Mary McCarron will share her insights from research  into the experience of those ageing while living with intellectual disabilities and Professor Ros Willis from Southampton will explore the impact of race, ethnicity and religion on the ageing, health, and social care process. Combined the insights provide pointers to what might be included in a fresh map of care. Not the final word but initial cartography from which to develop the task.

For while the terms of care are blended, merged, unfunded, over funded, siloed and disaggregated by our media commentary and short cuts to the future of health and social care reform there still remains a truly creative and fully transparent new way forward to be debated.

About the Author

Francis Davis is Visiting Professorial Fellow in the Institute on Ageing Population and  Head of Digby Stuart College and Professor of Civic Leadership and International Studies at the University of Roehampton.  Zambian born he has held ministerial advisory roles in the UK government working on social inclusion aas well as  public appointments in the Department of Health and the NHS. He was Previously Professor of Public Policy at the University of Birmingham.