Empowerment in the New Era: A Perspective for Building Bridges in Care Systems

The Pillars for preserving personal health and social care in society are underpinned by involving family members during critical and substantial care needs of older people. Practice experience has uncovered that a large number of family caregivers are caring for their older relatives, offering them practical and psychological support. Some considers it to be their duty and responsibility thus, feeling guilty for not participating in the care of their older relatives. Most family members see the family care system as a link that connects the old and the young, as well as family history, which points them to the future. On reflection, family care giving includes personal care, nursing care to an extent, assistance with medication/drugs administration, housekeeping, transportation, meals preparation and assistance to feed.

The framework is drawn from several social psychological theories such as: Reactance Theory; Equity Theory and the Threat to Self-Esteem model, which identifies the psychological and environmental processes involved when people consider giving or seeking care assistance to older relatives. However, from a broader perspective there are a variety of factors which could influence the family care system or reciprocal family care for example, ageing and poor health of some family caregivers, financial wellbeing, and social needs, accessibility and environmental factors such as housing, transport, and cultural antagonism. Yet, the delivery of services; health and social care in particular are intertwined with education, knowledge and awareness of holistic assessment and care management.

In practice, older people appreciate value for money. This has been supported by both practice observations and research findings, which reveals that interdependence between family members in their own home would enhance the existence of care giving. Thus, better understanding is required regarding the impact of prolonged and complex care giving by strangers. In view of that, older people see respect and dignity as issues of great concern when it comes to receiving personal care from caregivers. Practically, older people do not feel comfortable with strangers assisting them with personal care but would accommodate their own family members as they understand their wishes and standard of care they are used to. This view draws reference from "Modernisation of Social Care" which demands proactive action to achieve better governance that is more responsive to the plight of older people. This means raising all services for older people to the standards of the best and recharging social services with fresh vigor, incentives and new ideas.

Older people deserve this right like any other citizen of the state and should receive quality care in their own home without prejudice (irrespective of gender colour of the skin and disabilities). However, in practice there have been wide variations in quality and in some areas ineffective and waste of resources. Thus, family involvements in care needs assessment and care would help to develop a consistent care approach that is based on family values, norms and principles, which could be cascaded from one generation to another. Thus, it is hoped, this practice would potentially ease the shortage of formal caregivers; reduce wastes and duplications in the social market. The family will be the champion of the care systems and support for older relatives. This care model would support personal social services in the wider welfare systems, promoting whole systems frameworks. Involving family members would re-invigorate care in the wider community as well as family networking which is geared toward supporting older relatives. The service framework would offer the opportunity to develop innovative and integrate services that provides greater choice and control of services for the growing older people population.

Involving family members during long-term care would promote users empowerment, which allows them to participate in their own care. Reflecting on practice experience, the presence of family members in care giving is more important to older people that enable them to regain health and confidence as opposed to when in receipt of professional help. The availability of family support is found to be an important factor in determining whether a service user can be discharged home from hospital, rather than entering institutional care. I believe that family support places a high value on kinship, kindness, caring attitude, reliability, un-hurried care, consistency and continuity of care. This model of care advocates a joint ownership of care management between the family and the service users who supposedly being the overall controller of their care. In most cases, ageing and cognitive impairment have limited the ability of many service users to understand and manage their care packages, without working alongside their families.

By contrast, family care systems could propagate some form of abusive situations during care giving. However, the principles of care needs assessment and care management dictates that the presence of an advocate would deter any act of gross abuse such as: financial; physical; sexual; emotional and neglect to the frail vulnerable older people and this collaborate with the “Department of Health (2000) (No Secret)”. To reduce this incidence, it would be reasonable to have a family caregiver and not necessarily a qualified social worker, someone actually being involved, who also has basic understanding and knowledge of the needs of their older relatives. Families play a crucial role in the lives of older relatives; family involvement is most often interpreted as an indicator of social support rather than an influence on decision-making and protection of the vulnerable older person.

In retrospective the dominant sociological view, for a number of years has been that; older people turn first to their families for help, then to neighbours and finally to the state, because they expect their families to help in case of need. In some cultures, not only does most care come from the family but that most people think that this is where the responsibility should lie. This view is central to the philosophy of community care and more prominently end of life care services for older people in the wider society. In hindsight, there is a need to reinvent family care giving as the norm to enhance older people's welfare and psychosocial wellbeing during longevity of care in the community.

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Rethinking Community Care in the 21st Century: The Perspective for Marketisation of Social Care

The agenda for marketisation of social care revisited familiar themes around the enhanced involvement of users in service delivery, upholding choice and control, increasing accountability and developing these by integrating a role for self-organisation and independent living within services. The modernisation of the social care market, drawing on the principle of provider/purchaser split (NHS and Community care Act (DoH 1990), managerialism in welfare services and best value cost effectiveness, provided a focus for delivering social care. Both the Conservative/Liberal Democrats government and New Labour administrations have pursued these ideologies. It also has included the privatisation of care for older people, raising the issue whether the for-profit sector in indeed likely to be the best option for good quality care, especially for frail older people.

A key feature of marketisation policy is about breaking down large-scale organisations providing social care and using competition to enable exit or choice by service users. The ideological position is to increase flexibility in the social care market as this would bring about equilibrium of demand and supply in the market. Individuals and groups at different positions on the political spectrum have promoted the idea of users’ rights to exercise choice in their use of public services. Progressive self-help movements have argued for choice as a means of promoting market-based solutions and curbing the power of the state (Clarke et al 2000; Leadbeater 2004; Cameron 2010; Ugwumadu 2011).

Marketisation significantly centred on issues of cost efficiency, consumerism, and responsibilities and cost savings, whereby the allocation of cash for care rather than services raised concerns as to the accountability of government monies.  Marketisation policy clearly presents significant opportunity for delivering personalisation of services through direct payments and individual budgets model and related support structure in the future social care market (Leadbeater 2004; Hasler 2006). According to Zarb and Nadash (1994) and Hasler (2000, 2006), they argued that direct payments is around 40% cheaper than direct provision. New Labour government assured in its positioning of direct payments and individual budgets as part of a wider marketisation of social care, established initially through the 1990 Community Care Act. This framed the market as an instrument for accessing choice and diversity in social care provision through the development of local care markets (Hasler 2006; DoH 2008).

The central doctrines for the Conservatives/Liberal Democrats government and  New Labour government’ agenda are: a focus on managerialism not policy and on performance appraisal and efficiency; the disaggregating of public bureaucracies into agencies which deal with each other on a user-pay basis; the use of quasi-markets and contracting out to foster competition; cost-cutting; and a style of management which emphasises, amongst other things, out-put targets, limited-term contract, monetary incentives and freedom to manage (Hood 1991; Osborne and Gaebler 1992; Leadbeater 2004; Cameron 2010). These ideological policy frameworks are fundamental principles behind the Big Society’s agenda to enhance the welfare systems. The Big Society project is claimed to offer the opportunity to deliver the personalisation agenda and to maintain cost effective social care.

However, many people would disagree with this position on the grounds illuminated below. For example, changes in delivering personal social services are accompanied by an increasing tendency to define home care intervention in terms of narrow tasks. This has resulted in complaints of unmet needs and lack of opportunities for more generalised social interaction between carers and service users (Sale and Leason 2004; Ugwumadu 2011). The continuous changes within social services’ policy and practice have influenced social work practice and social care delivery. According to Morris (1993a) and Glendinning et al (2002, 2009), changes in policy meant that social workers were no longer in a position to uphold social work ethical practice, but had to participate in a policy that deprived users of their rights and choices, as outlined in the National Health Services and Community Care Act (DoH 1990).

It is also possible to see the Community Care (Direct Payments) Act (DoH 1996 a & b), and the Carers and Disabled Children Act (DoH 20001 b) as an attempt by government to promote a distorted and flawed notion of empowerment by exit, shifting responsibilities to users. The aim was to control and reduce an escalation of public expenditure. In such a service, Leece (2000) claimed that it would be left to local authority social services departments to balance the books and reconcile the very real demand for direct payments with already stringent budget constraints. Pearson (2004a, b and 2006) noted the contradiction and tension between the legislation and practice.

The Conservatives/Liberal Democrats government has largely intensified the marketisation approach as the basis of their broader modernisation programme in social care with its increasing focus on personalisation services. The Big Society project and Personalisation of services are very potent but, highly contested and ambiguous idea that could be as influential as a privatisation was in the 1980s and 1990s in reshaping public provision.

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Reconstruction of Social Work Through Personalisation

  This book is aimed at bridging the gap in the existing literature in the field of social policy for older people; personalisation of services, family reciprocity and education regarding contemporary social care and the social care market in the UK.  While there are publications in social inclusion and personalisation, yet, they do not look at the inter-relationships between personalisation of services for older people, family reciprocity and payment to informal family caregivers. In essence, life long learning by service users and their informal carers are lacking and as a result they are not conversant with developments within the system, therefore do not know how to access services within the wider welfare systems. Publications on longevity of care giving to older people, care needs assessment and demographic change also do not focus on life long learning. Thus, this book aims to break new ground by linking these important issues.  However, it might be unusual within older people service and long-term care literature to have a focus on the learning needs of a particular population for example; those with long term health and social care problems.

  This book has revealed the views of the key stakeholders (service users, family caregivers, social workers, social work managers and councillors) about the potential of family care giving. The majority profess the need for a changed social work practice in order to offer personalisation of services to the growing older people population. In as much as transformation and personalisation are the “buzz words” in social services, yet, many older people would prefer their family members to help them with their social care needs. This view is supported by both practice experiences and empirical research carried out in Essex County Council area of the United Kingdom (Ugwumadu 2010). Thus, the aim of this book is to modernise social work practice in line with the aspirations of the baby boomers that are now entering the social care market. This would provide the opportunity for power balance from the professionals “do it all” to the family members who would carry out assessment of care needs and provide care for older relatives for payment if they wish to.

  This book has also highlighted the interrelationships between health and social care for which longevity of care is now prevalence in our society. Presently social policy for older people, in particular the NHS continuing  healthcare for older people, is undergoing a considerable paradigm shift in terms of re-thinking core services that have been taken for granted such as collective welfare systems, ability for social inclusion, informal care, education, training, empowerment, and the meaning of recovery from physical disabilities. The re-thinking is accompanied by a slower pace of changes in social care and clinical practices, albeit no less significant, and at times with projects reflecting a leap into the new world of personalisation services.  

The book can be bought from major bookstores and Amazon: (www. Amazon.com)