Personalisation: Structure and Agency

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.

Social Care - What's that then?

What is social care?

To those of us who work in the sector that is probably an easy question to answer, although I suspect many of those answers will actually be slightly different, but what does it mean to the general public and the mainstream media?

It is perhaps the vaguest of all social policy areas after all most social policy is easily understood. Housing refers to where people live and the links between poor housing, welfare and deprivation are fairly easy to see to the average person (obviously to specialists things are much more complicated than that). Education means teaching our children to learn and, while there may be arguments on the best way to do this, when politicians talk about education the general public knows it is about schools, colleges and universities. Employment is about getting people to work and ensuring that the conditions of work protect employers and workers. Welfare is about the State supporting those in need, yes they is a debate about how you define that need but we all understand what is meant by welfare.

Health is also an easy issue to understand, it is about our physical and mental well-being. If we are ill we see a doctor, the type of doctor we see depends on what is wrong with us. We would expect our G.P. to refer us to the appropriate specialist in either physical or psychological issues and then expect to be treated by them, and that the system that the general public expect social policy to support. One of the reasons for the animosity toward the Health & Social Care Bill is the worry that changes may make this system different and more difficult to achieve the best possible results for our own health.

But what about social care? How easy is it for the average person to understand what social care means when politicians and professionals talk about it?

In 2006 the Department of Health described social care as “the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships” (DH (2006) Our health, our care, our say: a new direction for community services.)

Yet does that really mean anything to the average person?

Take, for example, services to support people to “enable them to play a fuller part in society”. The majority of people tend to think of social care as services for the elderly, something not helped by politicians who insist on focusing on how elderly care is paid for, and would find it hard to see what playing a fuller part in society would actually mean. After all for most people life does not involve “society”, it just revolves around work and home life (yes I know that is society but how many people think of it like that).

Social care does, naturally, support people to play a part in society, beyond supporting older people, support for people with disabilities involves trying to enable people to getting employment and if that is not possible ensuring that they receive their full entitlement of benefits (but, says the average person, isn’t that employment & welfare policy?)

Social is, or should be, about promoting and maintaining independence and enabling people to live where they want to live and ensure they are living in accommodation that is most appropriate to their needs. It is about ensuring that people have the adaptations and support in their home or, if their needs are greater that they can find accommodation in a home that will allow them to be as independent as possible whilst minimising potential risk (but, says the average person, isn’t that housing policy?)

Perhaps the mainstay of social care is providing personal support for people who are no longer able to support themselves. The reason for not being able to support themselves is generally down to physical or mental deterioration, age related conditions can be physically disabling and diseases, such as dementia, impact on the mind. The role of social care is to ensure that these people have support in maintaining their physical and mental well-being (but, says the average person, isn’t that health policy?)

There has been a lot of talk about integration in social care but the real fact is that social care is the integrating service.

Social care should be about bringing all other policy areas together for the benefit of those who need them. Social care should be seen as the umbrella under which all other policy areas sit because all of the areas could may need social care intervention. This is especially true if we include children’s as well as adult services in our overall definition, education, housing, welfare, employment and health all have an impact on the “social” and where they fail it is down to social care to step in to aid the individual, whether vulnerable child or adult, and support them to achieve the best possible outcome.

To raise awareness of social care we need to be able to define it in a way that the general population can understand and that definition should be one that shows the importance of social care as a policy area that embraces and sits above m