A basic common debate within social sciences is the question of structure versus agency, how the social structures of society impact on us as individuals and how our individual choices and freedoms are constrained by those social structures.
These arguments need to be considered in relation to social care, particularly personalisation.
The Social Care Institute for Excellence give us the following definition for personalisation;
"Personalisation means thinking about care and support services in an entirely different way. It means starting with the person as an individual with strengths, preferences and aspirations, and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives. It requires a significant transformation of adult social care so that all systems, processes, staff and services are geared up to put people first"
This shows the intrinsic link between structure and agency within delivering personalisation. It could also be argued that it demonstrates why personalisation has been difficult to achieve and why personalisation will never be truly personal unless there is a major change in the way social care is structured.
The SCIE definition describes the individual as being at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives.
In other words, the person is at the centre of the structure! But, how much is their individual agency constrained by that structure.
Unfortunately that structure is one that limits those choices available for personalised care and support and it is a multi-layered structure, each layer filled with bureaucracy and each layer with, at times, competing agendas.
The big, over-arching layer of structure in social care is, of course, Westminster. Parliament set out the laws and regulations under which social care is practiced in England, it sets out how social care is funded and it sets the structure under which personalisation can operate. This is all administered by the Department of Health who, as is its name suggests, has a primary focus on health and while many aspects of social care may overlap with health there are many other areas, such as housing and welfare, that do not.
The next layer in the structure is the most diverse and, perhaps, Weberian in its nature and that is the delegated bureaucracy. The role of implementing and enforcing the dictates of Westminster is handed down to a myriad of Quango’s (e.g. CQC, NICE etc) who have their own structures for implementing the written law handed down to them and of course, 152 local authorities with responsibility for commissioning state funded care and again with their own structures and political leadership which may vary from that sitting in Westminster.
The next layer surrounding the individual is the providers of care services. This is not just care homes or home carers, it also includes Social Workers who provide a service on behalf of the local authorities, providers of advocacy services, services which provide employment opportunities etc.
Eventually we reach the person needing care and support services.
Whichever way you look at it, as a top down structure or a circle with the individual at the centre, the layers of structure hamper the ideals of personalisation.
Those who provide services can only do so in controlled circumstances, they must be appropriately registered or have an appropriate contract and the services must be provided within the budget available. For those who need to choose services the choice becomes limited by these structural constraints, even those who have personal budgets or direct payments have the budgetary implications to consider. Whatever an individual’s strengths, preferences and aspiration, services can only operate within the structure dictated by the layers that surround care provision and the rules and regulations imposed on them.
This is not to argue that such constraints should be removed but that the structure should be revisited if we are to improve social care services and increase the opportunities for greater personalisation.
We are trying to move from a top down structure to one that has the individual at the centre yet the actual structure remains the same and has the same constraints on agency. If we want to change the outcomes for individuals we need to take a real look at the structure within which social care operates.