Sharpening the care diamond

A society’s capacity for providing care (which, as one reader pointed out to me, is not the same as how much it cares) can be seen as a diamond comprising the market, the state, close family and the wider community.

Thinking about how to generate more and better care involves looking at how we might increase the contribution from each source but also thinking about the relationship – sometimes additive sometimes subtractive – between them.

Care funded by the state is perhaps the most straightforward to analyse in the sense that it is fully stretched and it is difficult to see any significant increase in capacity in the foreseeable future. In terms of the overall pattern, the last decade has seen an increase in state support for child care (although under the Coalition it has been a  case of swings and roundabouts as the child care element of tax credits has been reduced but the entitlement to nursery provision has increased). In relation to adults and older people, some national care-related entitlements have been tightened while at the local level provision is now limited to the most needy.

The market for care is also very stretched. The private provision of care is expanding in line with need but in all domains of care there is a major affordability gap between what the market can offer – even paying rock bottom wages – and what most people can afford. Austerity is also putting ever greater pressure on the publicly funded aspects for private care. For example, there is a growing gap between the cost the private sector charges self-funding clients of residential care and what it is able to charge increasingly cash strapped local authorities.  Coalition ministers had expressed the hope that the implementation of a new long term care funding framework could create an opportunity for a new care insurance market to emerge. But such hopes have been expressed - and dashed - before.

When it comes to families the top line is that informal familial care is the bedrock upon which the whole societal care system rests. On the one hand, nearly all parents enthusiastically provide loving care for their children; on the other, a recent ONS analysis of the 2011 census estimated the total weekly provision of informal adult care in England and Wales at 3.4 million working days (up substantially on ten years ago). In rough terms, valuing an hour of unpaid care at the minimum wage level this means that unpaid care is worth about £170 million per week or about £8.5 billion per year. In fact the value is much greater as those cared for at home are also being housed and fed by their loved ones.

Arguably the problem of informal care by families is oversupply. While parental negligence and ‘granny dumping’ is still very rare, some care, both for children and adults, is not as good as it could be if informal provision was mixed with formal care. Vitally for the economy, levels of employment of mothers and people over fifty are lower in the UK than many other advanced economies. The need to provide care and the costs of buying it are the crucial factor inhibiting mother’s employment and an increasingly important factor keeping older people from full time employment.

This leaves the fourth point of the diamond, the community. We might define this as the contribution voluntarily made by people other than close family to the provision of care. This primarily comprises volunteer time but other contributions include money (in the form of philanthropy), the provision by employers of flexible working and, more generally, the framework of norms and values which shape the status of caring and the degree to which we see it as a collective responsibility.

In relation to this aspect today sees two contrasting contributions. This Guardian piece from Erin Mee http://www.guardian.co.uk/society/2013/feb/26/care-workers-plea-older-people-lonely underlines how much unmet need for even for the simplest forms of care there is lurking in every community. NESTA has today published a new report on a system response to , the Endowment is also calling for new ideas for its website celebrating innovative responses to ageing .

As NESTA says, many innovations can work alone and do not require or benefit from a system wide approach. But, as the report also says, despite lots of activity and concern about ageing social innovation is lagging behind technological innovation and we have a very fuzzy idea of what actually works, which is perhaps why we need to shift our whole orientation.  But if we do need to look at the system, what is the system? Is it the system of ageing, the system of care, or more narrowly the system of older care and the system of child care?

My feeling now is that, firstly, there is something essential to the human activity of providing all forms of care, and, secondly, there are common issues and dilemmas in the mixed systems of care which apply to children, adults and elders. This is why it is caring which should be the focus of our system view rather than a particular demographic group.

But, as is always the case when I start thinking in earnest about my annual lecture, I may well change my mind several times before I reach any kind of conclusion.