As the prospect of a National Care Service becomes imminent, it becomes all the more important that any such service is built on solid foundations.
One of those foundations must be an understanding of what “care” actually is.
Mark SmithDownload Now
Current day thinking on social care is framed by the neoliberal political and economic ideologies that emerged over the course of the 1980s and 1990s. Based around principles of economy, efficiency and effectiveness, these commodified care and took it into the marketplace. At another level, neoliberal ideology, emphasising as it does qualities of autonomy, competition and independence, failed to adequately recognise the relational dimensions of care within which dependency is often central.
There is a well-developed body of philosophical literature on care, which is not recognisable in either the Feeley Review or in the Scottish Government’s current proposals. In particular, the focus on rights, which is at the heart of and which seeks to furnish the proposals with some theoretical ballast, offers an inadequate paradigm within which to locate care, a point this paper returns to. The failure to engage with some of these deeper philosophical debates is likely to limit the range of possibilities that a National Care Service might offer. The intention of this paper is to outline some philosophical perspectives on care, with a Scottish flavour.
― Covid has changed the discussion about care, moving it on from the crude efficiency and cost priories of the 1980s and 1990s. This is a step forward but is insufficient; the approach is still largely managerial and bears little if any relationship with the widespread international body of academic work on care and how to make it successful.
― The current Scottish Government consultation contains no discussion of what care is, what it’s for or how it would look and feel for those being cared for.
― Rights are entirely the wrong framework for care. Rights is a theory of justice rather than of care. Even if rights were an appropriate framework within which to deliver care, such an approach can only happen if mediated through caring relationships.
― And rights mean nothing if there is no ability to access them – either because of poorly-resourced services or because the individual is incapable of either fully understanding or taking action to ensure their rights are met (as is often the case in a care relationship, for example with children, adults with learning difficulties or those with dementia).
― Instead, care should be based on building and sustaining relationships with those who are cared for. This involves moral and emotional investment from workers. The culture of separating rational/intellectual factors from intuitive/ emotional ones in care in a false pursuit of ‘professionalism’ has harmed relational approaches to care and instead promoted instrumental ones.
― Care theory moved on from managerial assumptions a long time ago but Scottish public policy has not. Only sustained, caring relationships are capable of accurately assessing and meeting this change. You cannot separate emotional and intuitive approaches to care any more than you could remove rational and skills-based approaches.
― Care is not ‘an intervention’, it is a continuous series of relationships we all have in many different settings, most of them informal. You can’t deliver formal care without recognising and working with the reality of informal care, whether familial or community-based.
― Care is also political. It is impossible to separate the care we experience formally or informally from the context of the services and policies in which these take place. This is recognised in the Nordic care model where the concept of care is explicitly ‘an art and an act’ structured around good public services and localised delivery.
― The Scottish Government has set ‘flourishing’ as an objective for those in receipt of formal care but has not engaged with the academic literature of what ‘flourishing’ actually means or how it can be measured and assessed.
― Professional social work has, historically, been slow to adapt to new theories of care and is often stuck in the ‘managerial’ model, insufficiently focussed on relationships. This depersonalises care – we care because the rules say we must, not because professionals have a relationship with a person who needs care.
― This is in part because there is too much focus on ‘protection’ rather than care. Caring would take into account the concerns and needs of the individual while protection assumes bad intentions on the part of the individual and often fails to go beyond that. ‘Caring about’ outcomes is abstract; we need to ‘care for’ and ‘care with’ the specific person.
― The predominant orientation in care has become one of ‘safety’. This is even more true of organisations and institutions than individuals. Fear of reputational risk is often a greater driver of policy and practice than the need to care is.
― This leads to risk-aversion in the workforce which, along with poor terms and conditions leading to high turnover and lack of proper training, creates a workforce incapable of delivering the right kind of long-term, relational care.
― There is no evidence that this regulatory approach has improved services but it has clearly disempowered professionals and carers. It is incentivising risk aversion much more than it is incentivising effective care approaches. This is not to argue there should be no accountability, but that it should be designed in a way that enhances the experience of care for people who need it and not the managers who manage it.
― The integration of care into health has dragged care further from its purpose; health and care are practices based on different orientations towards knowledgeand the current dominance of health over care is harming the practices of care. Sometimes just ‘being with’ rather than ‘doing to’ is key to social care, but this can be less the case for health care.
― Current care policy (like health policy) takes insufficient account of inequality and the ability of different groups to access services based on personal circumstances and conditions. Its one-size-fits-all approach is anathema to relationally-based care.