Caroline Glendinning

Dependence, independence or inter-dependence ? Revisiting the concepts of ' care' and ' dependency '

Research and theory on ‘ dependency ’ and ‘ care-giving ’ have to date proceeded along largely separate lines, with little sense that they are exploring and explaining different aspects of the same phenomenon. Research on ‘care ’, initially linked to feminism during the early 1980s, has revealed and exposed to public gaze what was hitherto assumed to be a ‘ natural ’ female activity. Conversely, disability activists and writers who have promoted a social model of disability have seen the language of and the policy focus upon ‘care ’ as oppressive and objectifying. ‘ Dependency ’ is an equally contested concept: sociologists have scrutinised the social construction of dependency; politicians have ascribed negative connotations of passivity ; while medical and social policy discourse employs the term in a positivist sense as a measure of physical need for professional intervention. Autonomy and independence, in contrast, are promoted as universal and largely unproblematic goals. These contrasting perspectives have led social theory, research and policies to separate and segregate the worlds of ‘ carers ’ from those for whom they ‘care ’. Drawing on the work of Kittay and others, this paper explores the ways in which sociological perspectives can develop new understanding of the social contexts of ‘ care ’ and ‘ dependence ’.

Gender and Poverty

A recent edition of this Journal (Volume 16, Part 2, April 1987) was devoted to a number of articles on the definition and measurement of poverty. Surprisingly, perhaps, this did not include any specific discussion of gender differences in the causes, extent and experience of poverty. But such gender differences do exist, though they are often obscured by much research on poverty. Our initial response to the special edition on poverty was to write a reply discussing how the various contributors had ignored the issue of gender. But women cannot simply be ‘added in’ to existing analyses; instead a different analytic framework is required. This article therefore begins by looking at some of the widespread evidence of the economic disadvantage of women compared with men. We then go on to discuss why it is necessary to focus on the gender dimensions of poverty. We argue that this involves far more than simply disaggregating data to produce statistics about the situation of women. Rather, this focus leads us to explore the structural causes of womens poverty and the gendered processes in the labour market, welfare systems and domestic household which interact to create and maintain that disadvantage. In the final section we consider some of the important conceptual and methodological issues which must be tackled if we are to find ways to investigate and measure poverty which are not gender-blind.

Beyond Modernisation? Social Care and the Transformation of Welfare Governance

This article reflects on the process and outcomes of modernisation in adult social care in England and Wales, drawing particularly on the recently completed Modernising Adult Social Care (MASC) research programme commissioned by the Department of Health. We begin by exploring the contested status of ‘modernisation’ as a descriptor of reform. We then outline some of the distinctive features of adult social care services and suggest that these features introduce dynamics likely to shape both the experiences and outcomes of policy ambitions for modernisation. We then reflect on the evidence emerging from the MASC studies and develop a model for illuminating some of the dynamics of welfare governance. Finally, we highlight the emerging focus on individualisation and on user-directed and controlled services. We argue that the current focus of modernisation involves a reduced emphasis on structural and institutional approaches to change and an increased emphasis on changes in the behaviours and roles of adult social care service users. This focus has implications for both the future dynamics of welfare governance and for conceptions of citizenship.

Assessing the Role of Increasing Choice in English Social Care Services

This article aims to explore the concept of choice in public service policy in England, illustrated through findings of the Individual Budgets (IB) evaluation. The evaluation tested the impact of IBs as a mechanism to increase choice of access to and commissioning of social care services around the individual through a randomised trial and explored the experiences and perspectives of key groups through a large set of interviews. The article presents a re-examination of these interview data, using three ‘antagonisms of choice’ proposed in the literature – choice and power relations, choice and equity, and choice and the public nature of decisions – as organising themes. The randomised trial found that IB holders perceived they had more control over their lives and appreciated the extra choice over use of services, albeit with variations by user group. However, problems of power relations, equity and the constraints implied by the public nature of decision-making were complicating and limiting factors in producing the benefits envisaged. The focus on choice in policy, especially as implemented by IBs, emphasises an individualistic approach. The findings suggest that addressing broader issues relating to power, equity and an understanding of the public nature of choice will be of value in realising more of the benefits of the policy.

Making informed choices in social care: the importance of accessible information

The current policy trend is to encourage greater choice in the use of welfare services. To make informed choices, people need information. The process of finding and using information has costs for individuals in terms of effort, time and material resources. These costs are different for different people and impact on their use of information in different ways. Thus, the accessibility of information is important in ensuring those people who need to make choices can do so in an informed way. This paper discusses the importance of information in making informed choices about social support by drawing on the findings of a scoping review of government research and development activity on the accessibility of information about adult social care services. The scoping review was carried out in spring 2006. Details of recent, current and planned projects were obtained through discussions with staff in government departments, government agencies and other related organisations identified using a snowballing technique. Forty-two contacts were made. Eleven research and 36 development projects were identified that aimed to investigate or improve the accessibility of information about social care services. A limited literature search was undertaken on information needs in areas not already under investigation by government. Eighteen articles were identified. Information and helpline staff from six voluntary organisations gave their views on the accessibility of information about social care services. Our findings show that there is no government-related or other recent research evidence on the specific information access needs for some user groups and services, for example, people from ethnic minority groups. For other user groups, such as people with chaotic lifestyles, there is evidence on information needs but no current or planned development projects to address these needs. The implications for the costs of finding and processing information to aid informed choices are discussed.

Older people's experiences of cash-for-care schemes: evidence from the English Individual Budget pilot projects

ABSTRACT Cash-for-care schemes offering cash payments in place of conventional social services are becoming commonplace in developed welfare states; however, there is little evidence about the impact of such schemes on older people. This paper reports on the impact and outcomes for older people of the recent English Individual Budget (IB) pilot projects (2005–07). It presents quantitative data on outcome measures from structured interviews with 263 older people who took part in a randomised controlled trial and findings from semi-structured interviews with 40 older people in receipt of IBs and with IB project leads in each of the 13 pilot sites. Older people spent their IBs predominantly on personal care, with little resources left for social or leisure activities; and had higher levels of psychological ill-health, lower levels of wellbeing, and worse self-perceived health than older people in receipt of conventional services. The qualitative interviews provide insights into these results. Potential advantages of IBs included increased choice and control, continuity of care worker, and the ability to reward some family carers. However, older people reported anxieties about the responsibility of organising their own support and managing their budget. For older people to benefit fully from cash-for-care schemes they need sufficient resources to purchase more than basic personal care; and access to help and advice in planning and managing their budget.

Negotiating needs, access and gatekeeping: developments in health and community care policies in the UK and the rights of disabled and older citizens

This article argues that the cumulative consequences of community care policies in the UK have resulted in a move from universal access to NHS services to discretionary access to residual local authority services. Drawing on an empirical study of the experiences of disabled and older people in obtaining access to community care assessments, the article argues that the traditional ‘gatekeeping’ activities of professionals have been augmented by a range of managerial and bureaucratic gatekeeping procedures. It examines the implications of these additional layers of gatekeeping for disabled and older peoples status as citizens.

Partnerships, performance and primary care: Developing integrated services for older people in England

The development of health services in England is currently shaped by three key factors: the active involvement of front-line health professionals (particularly family doctors – general practitioners) in decisions about resource allocation and service development priorities; the promotion of ‘partnerships’ between health and other organisations in order to deliver ‘joined-up’ services; and the close performance management of organisations and professionals to ensure that they meet externally prescribed objectives and targets. This paper considers the implications and impact of these factors on the development of services for older people. It discusses whether, under these circumstances, health service developments are likely to address some of the most pressing needs of older people.

Making choices about support services: disabled adults’ and older people’s use of information

This paper explores how disabled adults and older people find and use information to help make choices about services. It presents findings from a qualitative longitudinal study in England. Thirty participants had support needs that fluctuated, meaning that additional services might be needed on a temporary basis; and 20 had the sudden onset of support needs resulting from an accident or rapid deterioration in health. Each disabled adult or older person was interviewed three times between 2007 and 2009, using a semi-structured topic guide. They were asked to discuss a recent choice about services, focussing, amongst other things, on their use of information. Interviews were transcribed and coded, then charted according to emergent themes. A wide range of choices and sources of information were discussed. These were dominated by health and to some extent by social care. Key findings are that information was valuable not just in weighing up different service options, but as a precondition for such choices, and that disabled adults and older people with the gradual onset of support needs and no prior knowledge about services can be disadvantaged by their lack of access to relevant information at this pre-choice stage. Timely access to information was also important, especially for people without the support of emergency or crisis management teams. Healthcare professionals were trusted sources of information but direct payment advisers appeared less so. Ensuring that practitioners are confident in their knowledge of direct payments, and have the communication skills to impart that knowledge, is essential. There may be a role also for specialist information advocates or expert lay-advisers in enabling disabled adults and older people to access and consider information about choices at relevant times.

Personal budgets and the workforce implications for social care providers: expectations and early experiences

Drawing on two studies in England, this paper explores the workforce-related impacts that social care providers envisage, and have so far experienced, from an increase in the number of people using personal budgets. It presents findings in relation to financial and workforce planning, recruitment and retention, workforce training and service user/provider relations. The discussion considers the implications not only for providers but also care workers, service users and local authorities.