What is Care?
Professor Mark Smith - 4th November 2021
The Common Weal Care Reform Group has met regularly over the past year to discuss the possibilities that might come from a National Care Service. Several of us remember the optimism that was around in the years following the Kilbrandon Report. Kilbrandon changed the paradigm within which juvenile justice had previously been framed and, out of this, developed a wider vision of a cradle to grave social work service.
The recent Scottish Government commissioned Review of Adult Social Care, chaired by Derek Feeley, claims to want to change the paradigm within which care is delivered. The Scottish Government response to this goes even further in envisioning a National Care Service that spans all client groups, holding out the prospect of a service that parallels the National Health Service in offering care to everyone who needs it. Common Weal’s position is that this should be free at the point of need and that care should be seen as a common good rather than a commodity for private profit.
Having signalled a paradigm shift, Feeley does little to indicate what this might entail. His proposals appear to be stuck in the current neoliberal paradigm, based around private sector financing models, new public management mantras of improvement, ever-more regulation and a taken for granted assumption that health and care should be aligned. They also seek to centralise care provision with the Scottish Government, via the current Integrated Joint Boards, further eroding the democratic role of local authorities in responding to community needs. Feeley seeks to offer some ballast to his proposals by reiterating the warm words beloved of the current Scottish Government that services ought to be rights based. This may satisfy a political desire to sound progressive, but it is largely meaningless.
The major obstacle to Feeley and the Scottish Government being able to bring about a paradigm shift is that, in focusing on service delivery, they fail to engage with any idea of what it is that is to be delivered – what is this thing called care? My paper for Common Weal which was published this week addresses that question, setting out a case for the importance of care to human beings and the implications for a National Care Service. Unless the Scottish Government takes this as a starting point, the likely result will be that social care will continue to be conceived of as a largely instrumental task (often delivered in short time-blocks) with a primary mandate around protection and safety.
My argument, developed with other Care Reform Group members, is that care is not just a service to be delivered, but is also fundamentally relational. Human beings do not merely go about fulfilling mandated caring duties but do so in relationship with those they care for. Care is not a unidirectional transaction but reflects the engagement between inter-dependent, relational beings and emerges out of the nature of the relationships that develop between the care giver and care receiver over time.
Care is both an activity and a disposition; it is not merely about following procedure or doing one’s duty but should be carried out in a manner that conveys a sense of ‘mattering’ to the one cared for; competent care practice in the absence of a caring disposition is unlikely to be experienced as caring.
A relational conception of care makes it difficult to standardise it as a managerial logic seeks to do; each care relationship will and needs to follow its own course. Sometimes that might mean just spending time with someone, doing nothing beyond sharing a cup of tea and listening to one another’s stories. This everyday ‘being with’ aspect of care involves a knowledge base, rooted in practical-moral involvement; social care is about the art and craft of everyday life.
This brings me back to the problem with rights. Rights speak of a justice rather than a care orientation to human relations. They create a set of obligations and duties on those conferring the right (in this case the Scottish Government or any new body set up to manage the National Care Service). This implies that such institutional structures have the power and resources to enact such a right, a position that takes no account of an economic context of austerity and strictly limited resources. So, people may be identified as having a need, (re)framed as a right, but with no way to claim this. The only way to reconcile this tension is to set rights so low that they may allow people to survive but not to thrive. A rights-based approach will only raise expectations that cannot be met. Moreover, many of those needing care do not have the capacity to understand or claim such rights? In such instances, any such right can only be mediated through caring relationships, advocated for by family members or through skilled social care practice.
So, while Common Weal welcomes the prospect of a National Care Service, current proposals are severely limited by their failure to engage with the question of what care is. Their central claim that it ought to be rights-based is wholly inadequate; a functioning National Care Service needs to start with relationships before it gets to the other three ‘r’s: rights, resources and responsibilities .
Professor Mark Smith was a practitioner and manager in residential child care settings for almost 20 years before entering academia. He taught a Masters programme in residential child care at the University of Strathclyde, was Senior Lecturer and Head of Social Work at the University of Edinburgh and is now Professor of Social Work at the University of Dundee.