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The Royal College of Psychiatrists Improving the lives of people with mental illness

THE MICRO-INSTITUTIONALISATION OF SOCIAL CARE PROVISION

Dr Robin Jackson

Dr. Robin Jackson

Visiting Research Fellow, Centre for Learning Disability Studies, University of Hertfordshire

Introduction

In a recent paper the Chief Executive of the National Development Team for Inclusion has made the sobering point that people with an intellectual disability in the UK have achieved little or no profile for most of the last twenty years (Greig, 2015). The author highlighted a meeting he had had with a senior government official where he was personally informed that any attempt to seek radical improvements for people with an intellectual disability in the UK would fail as the numbers were too small to warrant government action! This off-the-record judgement may well have been shaped by a perception of this particular population as having limited political leverage when set against constituencies with a higher profile (e.g. people with a physical disability).

 

 

Inclusion

Whilst it is clear that the various government departments involved with education, health, social care and employment seek to promote a policy of inclusion where people with an intellectual disability are concerned, it is an unsophisticated policy which takes little account of the profound differences within that population. Kavale has pointed out that supportive arguments for full inclusion have been primarily based on ideologies with anecdotal case studies and testimonials, but not on quantitative research evidence (Kavale, 2000).

 

The crucial point that advocates of the inclusion principle miss but which earlier writers took pains to stress is that inclusion is a philosophy and not a technology (Tizard, 1964; Nirje, 1969). It is a system of values and beliefs which should help guide, not dictate, thought and action. Thus empirical examination should replace polemics: not to do so is to engage in a massive programme of social engineering (Zigler, Balla and Kossan, 1986). Zigler and Hall (1986) have argued that we should avoid adopting an all-or-nothing attitude in any debate about providing appropriate services for people with intellectual disabilities. They noted that there are many forces at work that depict issues as being either-or choices, driving out the middle ground position. In their judgment anyone who polarizes the situation by promoting one solution to the total exclusion of all others does that situation and its complexity a disservice.

 

What is urgently required now is an approach that is open, evidenced, and respectful. It is a system of values and beliefs which should help guide, not dictate, thought and action. This necessitates a sensitive and pragmatic approach, not an inflexible and dogmatic one.

 

This paper derives from the report by The Centre for Welfare Reform: ‘Who cares?’  The impact of ideology, regulation and marketisation on the quality of life of people with an intellectual disability (2015).      http://www.centreforwelfarereform.org/

 


Marketisation of care

The reforms implemented following the ‘commercialisation’ of care resulting from the National Health Service and Community Care Act (1990) brought about far-reaching changes to the provision and financing of health and social care in the United Kingdom. Market forces received an enormous boost, ‘for-profit’ organizations became increasingly active, notions of ‘best value’ became increasingly relevant within funding formulae, and users of services were more likely to be involved in decision making (Knapp and Kavanagh, 1995). Market ideals as a key principle of public service provision continued to be an acceptable feature of the neo-liberal agenda pursued by New Labour. The marketisation of the social care sector continues despite the acknowledgement, in one of the first comprehensive reports on social care, that care services run by the ‘for-profit’ sector in England are consistently out-performed by those run by the ‘not-for-profit’ sector (Commission for Social Care Inspection, 2005). However, with the passage of time, competition is likely to favour those ‘for-profit’ companies that are able to maintain their competitive edge by keeping costs low. Pollock (2005) has argued that this is likely to be achieved through the recruitment of poorly paid, inadequately trained and under-motivated staff; the implication being that ‘not-for-profit’ organizations will be squeezed out, leaving commercial companies to dominate the market. Bakan (2004) has convincingly demonstrated how for-profit companies operating in deregulated systems invariably act in an aggressive, exploitative and self-interested manner. Are there any grounds for believing that care corporations will act differently?

 

A survey was recently undertaken by the independent think-tank Centre for Health and the Public Interest with the 211 local clinical commissioning groups (CCGs) which now spend 16% of their care budget in the private sector and which have a duty to manage, monitor and enforce the 15,000 contracts with private providers (Gallagher, 2015). It was found that of the 181 CCGs that responded to the survey only 16 (9%) had imposed any financial sanctions due to poor performance. Because of the apparent reluctance of CCGs to enforce contracts, the think-tank recommended that NHS England commission an independent audit of the CCGs’ capacity to monitor and manage contracts with non-NHS providers before any further major contracts are signed. What appears not to be called into question is the practice of contracting out services to the private sector.

 

A further consequence of the marketisation of social care has been the growing marginalisation of professional workers (e.g. doctors, social workers, educational and clinical psychologists, etc.) in decision-making processes related to assessment and placement. Decisions are increasingly being taken by local authority commissioners for services (Care Service Improvement Partnership, 2008). Thus a process of deprofessionalisation is occurring in which the role of those with relevant knowledge, expertise and experience and who are well placed to make informed decisions concerning the individual needs of clients are being sidelined. These changes appear to be driven by cost and not quality of life considerations.

Assistive technology

One strategy increasingly being deployed by a number of care companies to tackle the issue of high staff costs is the introduction of assistive technology to monitor residents. It is argued in defence of this practice that it protects the resident; acting as a safeguard, preventing abuse and encouraging good practice. However, by adopting such technology it could be argued that one is re-introducing some of the salient characteristics of the total institution identified by Goffman (1961):

  • individuals progressively losing their identity
  • constraints being placed on basic liberties (e.g., freedom of movement and action)
  • life within a setting becoming routinised and closely regulated
  • staff maintaining a social distance between themselves and residents.

 

If as a result of the introduction of assistive technology the size of a staff team in a care home is significantly reduced then this will limit the ability of the staff to accompany residents should they wish to leave the care home in order to go shopping, attend a recreational or social event or visit friends. In other words, the financial advantage gained by a ‘care business’ in installing assistive technology may be at the expense of curtailing the freedom of movement and action by residents. This limitation of access to the outside world can then lead to the creation of a quasi-custodial regime in which members of care staff increasingly find their role changing from that of carer to custodian.

 

The notion of the custodian is not farfetched. In the late 18th century Jeremy Bentham, English philosopher and social theorist, conceived of the construction of the Panopticon - a particular type of institutional building. The concept of the design was to allow a single person to observe the inmates of an institution without the inmates being able to tell whether or not they were being observed. Bentham saw the basic plan as being applicable to hospitals, schools and asylums as well as prisons. The Panopticon was intended to be cheaper than the prisons of his time as it required few staff.

 

Whilst Bentham regarded the Panopticon as a rational and enlightened solution to a societal problem, Foucault (1975) saw the Panopticon as creating a consciousness of permanent visibility which acted as a form of power. Contemporary social critics have argued that such technology has allowed for the deployment of panoptic structures throughout society (Elden, 2002). Surveillance by CCTV cameras in public spaces in the UK is an example of a technology that brings the gaze of some unknown and external body into people’s daily lives. Whilst Foucault accepted that the Panopticon was a form of architecture, it was above all else a form of government. It was a way for mind to exercise power over mind (1994).

 

Tunstall, a leading company in deploying assistive technology in the care home sector, has claimed that it is a cost effective alternative to traditional residential care for people with complex needs. It asserts that such technology enables “personalised care, choice, dignity and control” and provides the user with an enriched experience. In one example cited by Tunstall where assistive technology is in operation the physical environment of the resident is equipped with sensors that monitor a range of factors:

  • telecare sensors to manage possible fire, flood or gas leaks
  • personal pendants to enable residents to request assistance
  • sensors to alert staff if a resident has fallen
  • epilepsy sensors to reduce/remove the need for night-time checks
  • environmental sensors to control curtains, heating and lighting
  • sensors to access automatic doors.[1]

 

Depending on the ability of the individual, residents can also access Walled Garden, a portal which enables the user to pay bills, go shopping, contact their GP and access social networking sites in a safe environment using easy icons. There is an unconscious irony here in describing the portal as a Walled Garden in that it conveys the impression of an enclosed physical and social environment cut off from the world outside.

 

And the comparison with Bentham’s Panopticon is not far-fetched. Instead of one person sitting in the central watchtower with a clear sight into all the individual cells, we have one person sitting at a computerised central control console. And it is only a small step to having CCTV installed in each room to further monitor activity. What is disturbing is that this form of provision is represented as personalised care, yet what we are witnessing is a process of depersonalisation.

                     

A further problem is the tendency to equate technology with progress, when the contrary may be the case. Objections to the use of assistive technology (including CCTV) are not born of some Luddite tendency but from a fear that it may lead imperceptibly to the reinstitutionalisation of vulnerable people. Thus, before witnessing a further expansion in such provision there should be research - not sponsored by companies promoting and selling assistive technology - in order to assess its impact on the quality of life of people with complex needs. This might be thought a very appropriate topic for members of the Faculty of Psychiatry of Intellectual Disability to explore and research.

 

The apparent lack of interest by government in people with an intellectual disability, to which Greig (2015) has made reference, is a matter of concern as the kind of issues identified in this paper are likely to be ignored. But those who have been made aware of the detrimental impact of marketisation and the uncritical adoption of assistive technology on the lives of people with an intellectual disability and who voice no concern could be seen as complicit in the process of micro-institutionalisation.

 

 

 


References

Bakan, J. 2004. The Corporation: The Pathological Pursuit of Profit and Power, London: Constable.

Care Service Improvement Partnership. 2008. Commissioning for Personalisation: a framework for local authority commissioners, London: Department of Health.

Commission for Social Care Inspection. 2005. The State of Social Care in England 2004-05 (First annual report to Parliament on the state of social care), London: CSCI.

Elden, S. 2002. Plague, Panopticon, police, Surveillance & Society, 1(3), 240-253.

Foucault, M. 1975. Discipline and Punishment: the birth of the prison, New York: Vintage Books.

Foucault, M. 1994. Dits et écrits 1954-1988, D. Defert and F. Ewald (Eds.) Paris, Gallimard.

Gallagher, P. 2015. NHS struggling to monitor the safety and efficacy of its services outsourced to private providers, The Independent. 19 April.

Goffman, E. 1961. Asylums: essays on the social situation of mental patients and other inmates, San Francisco: Anchor Books.

Greig, R. 2015. The policy construct behind community care, International Journal of Developmental Disabilities, 61(2), 61-67.

Jackson, R. 2015. ‘Who cares?’ The impact of ideology, regulation and marketisation on the quality of life of people with an intellectual disability, Sheffield: The Centre for Welfare Reform.

Jackson, R. and Irvine, H. 2013. The impact of ideology on provision of services for people with a learning disability, International Journal of Developmental Disabilities, 59(1): 20-34.

Kavale, K. 2000. Inclusion: rhetoric and reality surrounding the integration of students with disabilities, The Iowa Academy of Education: Occasional Research Paper #2. Des Moines: FINE Foundation. May 2000.

Knapp, M. and Kavanagh, S. 1995. Market rationales, rationing, and rationality: mental health care reform in the United Kingdom, Health Affairs, September, pp.260-8.

Nirje, B. 1969. The normalisation principle and its human management implications. In R. Kugel and W. Wolfensberger (Eds) Changing Patterns in Residential Services for the Mentally Retarded. pp. 181-194. Washington, D.C.: President’s Committee on Mental Retardation.

Pollock, A. 2005. NHS plc: The Privatisation of our Health Care, London: Verso.

Tizard, J. 1964. Community Services for the Mentally Handicapped, London: Oxford University Press.

Tunstall Healthcare. 2015. A new approach to supporting people with complex needs using integrated technologies, Healthcare (UK) Ltd. http://www.tunstall.com/

Zigler, E., Balla, D. and Kossan, N. 1986. Effects of types of institutionalisation on responsiveness to social reinforcement, wariness and outerdirectedness among low MA residents, American Journal of Mental Deficiency, 91, 10-17.

Zigler, E. and Hall, N. 1986. Mainstreaming and the philosophy of normalisation, In: C. Meisel (Ed.). Mainstreaming Handicapped Children: outcomes, controversies and new directions, New Jersey: Lawrence Erlbaum Associates Inc, 1-10.


[1]Moorgate Mill, Blackburn: a 20 bed apartment for residents with complex needs.

 

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