The Scottish government has presented self-directed support (SDS) as an opportunity for people to gain choice and control over their social care. This has been welcomed in some respects, for example, disability rights activists have long argued that disabled people are not involved enough in discussions over their care. However, others have been concerned that moves towards SDS have been under-resourced and may undermine existing services, opening up gaps in the care and support of vulnerable people.
This debate has been preoccupying us at CommonHealth for a while, so this week Gill and Fiona have teamed up to unravel some of the issues.
The history of health and social care over the last 30 years has been very present in discussions of SDS. Academics have identified a policy trend towards ‘individual support and personalisation’. This can be placed within broader moves to situate the population as consumers of health, with public health messages that have increasingly urged people to take responsibility for their own ‘health and lifestyle’ since the 1970s. As well as this changing language, there have been important structural changes to the delivery of health and welfare support, particularly the transition to Care in the Community. Care in the Community must be understood in the context of the roll back of state services and the growing accommodation of the Third Sector; a trend started by Margaret Thatcher and continued by successive governments, often referred to as neoliberalism. This combination of the individualisation of public health, the positioning of patients as consumers and changes in the makeup of the health and welfare matrix explain how the language of control and choice in health and social care has gained ground over time; but are people really experiencing greater control and choice over their health and social care?
In a recent studies including our own, SDS payments were used by individuals as one part of a ‘mix and match’ approach to their care package. Social enterprises have seen the move to SDS as an opportunity to provide bespoke health and social care services, since clients can opt to use their SDS allowance to pay a social enterprise rather than statutory services. These social entrepreneurs have recognised SDS as an opportunity to generate more inclusive local services. For individuals with complex needs, however, we found that some recipients with fluctuating conditions revert to their previous provision as their health changed. For this particularly vulnerable group there is a danger that local authorities may cut back their social care provision, leaving the burden of support with the third sector and communities.
How can a balance between the opportunities of SDS to provide access to bespoke services be balanced with consistent access to social care?
If we travel back to the nineteenth century it is possible to identify a different set of values and ideas that prioritised collective rather individual health in contemporary social welfare debates. Mutual aid organisations in the form of Friendly Societies and Trade Unions provided a form of insurance for their working class members. The pay-outs that people received from Friendly Societies allowed them to pay for medical services, in some ways comparable to direct payments in the twenty-first century. Membership of Friendly Societies required attendance at meetings and visits to collect payments, maintaining social links within the community. It allowed people to take control and maintain a level of choice over their health and welfare, but as a community rather than an individual endeavour.
In rural Scotland, there are examples of micro providers forming cooperatives to match people with services and allow people access to new forms of care. These social entrepreneurs have recognised SDS as an opportunity to generate more inclusive local services, but will their efforts be enough to provide empowering forms of control and choice to patients and reverse the negative effects of individualised health and social care?
Gillian Murray & Fiona Henderson
Kathy Boxall et al, ‘Selling individual budgets, choice and control: local and global influences on UK social care policy for people with learning difficulties’, Policy and Politics, 37:4 (2009).