Defining responsibility for care: approaches to the care of older people in six European countries

This article examines the social care of older people in six contrasting European countries. Family, institutional and community care are compared, focusing on vulnerability, empowerment and the gatekeeping of resources. The article considers the position of older people in each care system by presenting individual case studies. The six countries include the family-oriented systems of Ireland, Italy and Greece, and the individual-oriented systems of Denmark, Norway and England. To improve the care of older people in any of these welfare cultures, resources need to be developed that work with existing sources of care but extend the rights of older people, at least to assessment and an equitable matching of needs to the care services available. Overall, the different levels of provision of organised social care services are a major aspect of inequality within and between the countries. Whilst there is little prospect for any major policy transfer across national boundaries, there is potential for selective cross-national learning with regard to particular service developments.     

Ageing and the changing role of the family and the community: An African perspective

Global ageing, the major social issue of the twenty-first century, will have greater social repercussions for developing countries. The fastest increase of older persons in terms of ratio in relation to younger people is happening in developing countries, and in Africa segregation of older people in rural areas will become manifest. While beneficial changes for women have accompanied modernization in many of the developing countries, the situation of older women appears to be particularly precarious. Social changes brought about by modernization are also profoundly affecting the traditional systems of care for older people. Even though most older people requiring care are still looked after within the informal structures of the family, this can no longer be taken for granted as we move into the new century. This paper critically reviews social protection systems and the resource constraints which characterize developing countries and warns against blind development of social security systems based on those of the industrialized countries. The paper argues for the design of intergenerational support back into mainstream social relations so that older persons are not marginalized and put at risk through social protection programmes which reinforce physical vulnerability stereotypes and stress welfare needs over and above older people's social and economic contributions to society     

Contentment and Suffering: the Impact of Australia's Housing Policy and Tenure on Older Australians

Housing policy in Australia historically has focused on facilitating homeownership and creating some buffer for those households that are not homeowners. This paper explores the implications of this policy for older Australians. What is argued is that housing tenure has become a crucial divide and that older Australians who have not had the good fortune to access homeownership or public / community housing and who are dependent on the private rental sector as a result, often find themselves in desperate circumstances. The argument is developed that the failure to put in place a housing policy which would give all citizens the ability to access adequate and affordable housing, has led to a situation where a substantial and increasing number of older Australians have untenable housing costs and minimal disposal income. The article concludes that the present policy initiatives aimed at addressing the housing affordability crisis will have little impact on the situation of older people who are currently in housing stress.     

Choice,Competition and Care – Developments in English Social Care and the Impacts on Providers and Older Users of Home Care Services

This article critically examines recent changes in markets for home (domiciliary) care services in England. During the 1990s, the introduction of competition between private (for‐profit and charitable) organizations and local authority providers of long‐term care services aimed to create a ‘mixed economy’ of supply. More recently, care markets have undergone further reforms through the introduction of direct payments and personal budgets. Underpinned by discourses of user choice, these mechanisms aim to offer older people increased control over the public resources for their care, thereby introducing further competitive pressures within local care markets. The article presents early evidence of these changes on:

• The commissioning and contracting of home care services by local authorities and individual older people.
• The experiences and outcomes for individual older people using home care services.

Drawing on evidence from two recent empirical studies, the article describes how the new emphasis on choice and competition is being operationalized within six local care markets. There are suggestions of small increases in user agency and in opportunities for older people to receive more personalized home care, in which the quality of care‐giving relationships can also be optimized. However, the article also presents early evidence of increases in risk and costs associated with the expansion of competition and choice, both for organizations providing home care services and for individual older service users.     

'Policies Don't Protect People, It's How They Are Implemented': Policy and Practice in Protecting People with Learning Disabilities from Abuse

Recent years have seen the development of policy guidance documents in both Wales and England relating to the protection of vulnerable adults from abuse. This policy guidance does, however, require translation into policies at the local level and that these policies are then implemented in day‐to‐day practice. This article reports some of the findings of a two‐year study that examined the development and implementation of such policies in services for people with learning disabilities within Wales. Data were gathered by means of a survey of service providers from across Wales and also via focus groups held with direct care staff and those with a responsibility for investigating alleged abuse. Positive developments include a commitment to multi‐disciplinary working, increased clarity and consistency, and greater awareness. Less positive aspects include the potential for policy ‘overload’ and a feeling that, while there is awareness of the existence of vulnerable adults policies, knowledge of their content may be more limited. Recommendations are made for the development of policy, practice and research.     

Autonomy,Choice and Control for Older Users of Home Care Services: Current Developments in Swedish Eldercare

In Sweden, a policy shift towards more individualized eldercare, with an emphasis on consumer choice, has taken place. The aim of this study was to analyze the processes and practices of individualized eldercare, focusing on preconditions for older peoples’ choice and control. Data consist of qualitative interviews with users of home care services (n – 12) and staff (n – 12) and participant observations (n – 7) of meetings between staff and older people. The choice and control available to older users emerged as decisions about ‘what’ care and services, ‘who’ should provide the care and services, and ‘how’ the care and services should be performed. Three approaches to enable older people choice and control over their home care services were revealed: test and revise, services elaborated in close collaboration between users, care managers and home care staff; choices in the moment, users could choose services at each occasion; and quality improvement through competition, competing providers develop attractive services. The findings could guide policy makers in combining the strengths of these approaches to enable older people in need of support to become co-producers in designing, managing, as well as consuming, care and services. Future quantitative research is needed to achieve generalizable knowledge about the strengths and weaknesses of different ways to organize eldercare services.     

Lay Assessors and Care Home Inspections: Is There a Future?

This paper reports on research funded by the Nuffield Foundationexploring the role of lay assessors in the care home inspectionprocess in England and Wales. Lay people have been includedin many care home inspections for the past decade. Similar layinvolvement is included in other public service inspectionssuch as the Office for Standards in Education (OFSTED) inspectionsof schools. The Board of the short-lived National Care StandardsCommission (NCSC) controversially decided to dispense with suchlay involvement in the inspection process. The replacement body,the Commission for Social Care Inspection (CSCI), intends toinclude lay people in the inspections of support services inthe community but is hesitating about reintroducing them intocare home inspections. This research project was able to explorethe role taken by lay assessors in thirteen inspections of carehomes for older people and for adults with learning disabilities.The research concluded that lay assessors had a significantrole in communicating with residents and staff and observingcare home life. Their role was particularly important, as inspectorswere often so involved in paperwork and checking policy compliancewith the national minimum standards that they were often ableto spend little, if any, time talking to residents or staff.It is argued that there is considerable potential for a strengthenedrole of lay people in the care home inspection process.     

Implementing Consumer Choice in Long‐term Care: The Impact of Individual Budgets on Social Care Providers in England

In common with many advanced welfare states, England has increasingly relied on consumerist principles to deliver both greater quality and improved efficiency in the long‐term care system. The Individual Budget (IB) pilots marked the next step in this process, through a new system of funding whereby greater control of resources is given to service users, in lieu of direct in‐kind care provision. IBs have the potential to transform the market for care services as well as the relationships between key stakeholders within it. Purchasing will increasingly be shaped by the demands of IB holders, with providers expected to deliver a wider range of personalized services. What will this mean for providers, and what can they do to prepare for these changes? These questions are relevant not just in England but in many other countries adopting similar mechanisms for devolving control over the design, delivery and funding of care to the end‐user. The article explores the early impact of IBs on providers' services, on their workforces, and on the administrative implications for providers of managing IBs. The study finds that providers were positive about the opportunities for better‐quality services that IBs can bring about. However, participants highlighted a number of obstacles to their effectiveness, and reported a range of potentially adverse administrative and workforce consequences which have the potential to jeopardize the consumerist policy objectives of increased choice and efficiency.     

Poverty Reduction: The Missing Piece of Pension Reform in Latin America

Employment‐based pension plans constitute the main form of pension provision in Latin America. Although recent pension reform in the region has focused on strengthening these, old‐age poverty remains high in most countries in the region, with older people over‐represented among the poor. The article argues that ensuring old‐age support for poor and vulnerable groups involves a different set of priorities and options for pension reform, namely a strong focus on tax‐financed public cash transfer programmes. Cash transfer programmes focused on poor older people are the missing piece of pension reform in the region. The article examines the experience of the handful of countries with such programmes in place, and draws the lessons for the future of social policy in the region.     

Partnership between the probation service and voluntary sector organizations

Summary This paper considers the development of inter-agency partnershipsbetween the probation service and voluntary sector organizationsin the early 1990s in England and Wales and reports the resultsof research by the author and their implications for youth justicearrangements outlined in the recent 1998 Crime and DisorderAct. The article outlines the development of probation partnershipsand the impact of changes to probation services, voluntary organizationsand service users which include: a shift towards purchaser-providerand contract-based arrangements; voluntary organizations takingon a role to work with involuntary clients; and the introductionof a discourse on partnerships which marginalizes small, informalvoluntary groups. These findings are then considered in relationto the Crime and Disorder Partnerships for crime preventionwhich form a crucial part of the 1988 Criminal Justice Act.The Crime and Disorder Partnerships have less emphasis on amanagerialist agenda but offer no extra resources and this articlesuggests that they may therefore not result in significant benefitsfor agencies working with young offenders.     

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

‘Replacement Care’ for Working Carers? A Longitudinal Study in England, 2013–15

In the context of rising need for long‐term care, reconciling unpaid care and carers’ employment is becoming an important social issue. In England, there is increasing policy emphasis on paid services for the person cared for, sometimes known as ‘replacement care’, to support working carers. Previous research has found an association between ‘replacement care’ and carers’ employment. However, more information is needed on potential causal connections between services and carers’ employment. This mixed methods study draws on new longitudinal data to examine service receipt and carers’ employment in England. Data were collected from carers who were employed in the public sector, using self‐completion questionnaires in 2013 and 2015, and qualitative interviews were conducted with a sub‐sample of respondents to the 2015 questionnaire. We find that, where the person cared for did not receive at least one ‘key service’ (home care, personal assistant, day care, meals, short‐term breaks), the carer was subsequently more likely to leave employment because of caring, suggesting that the absence of services contributed to the carer leaving work. In the interviews, carers identified specific ways in which services helped them to remain in employment. We conclude that, if a policy objective is to reduce the number of carers leaving employment because of caring, there needs to be greater access to publicly‐funded services for disabled and older people who are looked after by unpaid carers.     

The determinants of income mobility of older people in England and South Korea

This paper adopts a longitudinal approach toward examining what lies behind income mobility of older people aged 50 and over in England and aged 45 and over in South Korea over the period between 2006 and 2012, using panel data from the English Longitudinal Study of Ageing (ELSA) and the Korean Longitudinal Study of Ageing (KLoSA). The breakdown of income mobility which takes into account different type of division of the elderly population and income sources are also performed. The findings reveal that income growth has very little impact on aggregate income mobility in England, while it is crucial for the income mobility levels in Korea. There is a great deal of income mobility among single people under the age of 65 in England, while older people who are aged 65 or above and live alone experienced a greater variation in their income over time in Korea. In the case of breakdown of income mobility by income sources, it appears that labor income is the most important determinant of mobility in both countries and income from self‐employment for Korea and income from social transfers in England also plays an important contribution to income mobility.     

Personal Assistance for Disabled People – The Norwegian Experience

This article presents data from a survey of all disabled people in Norway who receive personal assistance in the municipalities that have been granted subsidies from the state. It concentrates on the following issues: – Who are the users of personal assistance? What distinguishes them from other disabled people? – What dimensions has personal assistance as a service? How has it influenced the total service to the recipients and how is this composed? – How do the users value the service? To what extent does it seem to fulfil the aims of self-dependence and sovereignty for the users? The article concludes that personal assistance seems to be a suitable instrument to reach the goals of full participation and equality of status for disabled people in Norwegian society. The main challenges which personal assistance will meet in the future are the financing of the arrangement and how the principles of user-determination could be implemented and transferred to other services without losing its ideological base.     

Prioritising care services: Do the oldest users lose out?

Population ageing is a major concern in most European countries. Demands for health‐ and care services will increase, as older people typically have a higher need for such services. What is often overlooked, however, is that older users increasingly compete with younger users for the same limited care resources. We ask: How do employees in the Norwegian care sector make decisions regarding the allocation of services to younger and older users? To answer this question, we interviewed decision‐makers in Norwegian municipalities. Despite providing for equal rights to services, laws allow for an interpretation of needs and this can result in the unequal distribution of services. Our study indicates that needs are defined differently for younger and older users, which affects the amount, type and content of the services allocated to younger and older people. When resources are scarce and priorities must be established, the services to the oldest suffer. Key Practitioner Message: ● The article lays the groundwork for an open debate about the allocation of resources to users in different life phases; ● The analysis conceptualises and makes explicit important normative decisions made by practitioners.     

From ‘Rights to Action’: practitioners' perceptions of the needs of children experiencing domestic violence

Not only has research over the past decade documented the emotional and behavioural consequences for children who witness domestic violence, but a number of studies have used children as participants thus, giving them an opportunity to describe their experiences in their own words. In policy terms, there has been a growing emphasis on children's rights and the importance and understanding of children's perspectives on their own lives. Consequently, children can no longer be perceived as forgotten victims where domestic violence is concerned. This paper explores practitioners' awareness of the needs of children and young people living with, and fleeing from, domestic violence. The research, conducted in a rural area in Wales, reveals that although the views of practitioners reflect the concerns reported by young people in other studies, there can be barriers to meeting these needs. While policy prescribes engaging with children, at the institutional level, operational priorities and increasing administrative demands can actually reduce opportunities for working directly with children. These demands may hamper the development of multi‐agency practice.     

A Brave New World of Personalized Care? Historical Perspectives on Social Care and Older People in England

Social care policy for older people in England continues to generate extensive discussion around the need to break with the past and to deliver a personalized response to need. This article explores the extent to which this represents a complete break with the past by looking at four key reports from the past, namely the Rucker Report (1946 ) on the break up of the Poor Law, the Seebohm Report (1968 ) on the personal social services, the Griffiths Report (1988 ) on community care and The Royal Commission on Long Term Care ( Sutherland Report, 1999 ). Each is interrogated in terms of how social care is defined, how services are to be delivered, how quality is understood and the assumptions made about who will be able to access services. This analysis is used to draw out key continuities in policy assumptions such as the primacy of family and the ongoing debate about ‘What is social care?’ and how it can be distinguished from health care. The article also argues that the voluntary sector has always been seen as a ‘key player’ in social care. Finally, the analysis of the four reports is used to trace the ever changing role of local authorities in the planning, purchase and provision of social care services for older people.     

Social Exclusion, Inequality and Social Work

This paper sets out the environment of inequality in which social work and the poor have recently operated. It explores pragmatic and idealist arguments concerning whether or not the poor need social work. Finally, policy solutions developed in consultation with social service users and carers are suggested in relation to poverty and social exclusion. Social exclusion can be linked to relative poverty as exclusion from economic and social norms. However, there is a wider brief in our own government’s publications and those of Europe, of examining how people are excluded from actions and policies of agencies who are there to support them. This paper will retain the concepts of poverty as lack of material income, and inequality as the gap between the rich and the poor, while being aware of the policy implications for social service users and carers of the more comprehensive process of being shut out partially or fully from social, economic, political and cultural systems. The debates around social work, social exclusion and inequality that follow establish: that some of the poor do need social work; that the poverty of social service users is related to policies that have restructured welfare in Britain; that the reason for individuals approaching or being referred to social services are complex but are likely to include financial deprivation as a key contributory factor; that if the poor do need social work, advocacy is essential rather than social work being seen as concerned only with social control—taking children into care, mentally ill people into hospitals, and advising the DSS on the suitability of claimants for benefits. Finally, the discussion turns to new policy agendas on social exclusion instigated by the Labour government. What positive difference can such policies make for social service users, their carers and social workers?.     

Coexisting principles and logics of elder care: Help to self‐help and consumer‐oriented service?

Healthy and active ageing has become an ideal in Western societies. In the Nordic countries, this ideal has been supported through a policy of help to self‐help in elder care since the 1980s. However, reforms inspired by New Public Management (NPM) have introduced a new policy principle of consumer‐oriented service that stresses the wishes and priorities of older people. We have studied how these two principles are applied by care workers in Denmark. Is one principle or logic replacing the other, or do they coexist? Do they create tensions between professional knowledge and the autonomy of older people? Using neo‐institutional theory and feminist care theory, we analysed the articulation of the two policy principles in interviews and their logics in observations in four local authorities. We conclude that help to self‐help is the dominant principle, that it is deeply entrenched in the identity of the professional care worker and that it coexists with consumer‐oriented service and without major tensions in the logics identified in their practices.     

Slicing Up the Pie: Allocation of Central Government Funding of Care of Older People

The allocation of central government funds is a critical element in the equitable provision of local authority‐commissioned and ‐provided services. A variety of approaches to allocating funding for social services for older people have been used over the years, most recently founded on ‘needs‐based’ formulae. In 2004, the Department of Health for England commissioned research to help inform the improvement and updating of the formula. The results of individual‐level analyses were compared with the results obtained from analyses of small area (ward‐level) data on service users. Both analyses were affected by problems of data availability, particularly the individual‐level analysis, and the Department of Health and the (then) Office of the Deputy Prime Minister decided that the formula calculations should be based on the results of the small area analysis. However, despite the differences in approach, both methods produced very similar results. The correlation between the predicted relative needs weights for local authorities from the two models was 0.982. The article discusses the strengths and weaknesses of each approach and developments that could allow a normative approach that would incorporate future policy objectives into formulae that, to date, have inevitably been based on historical data and service patterns.