The Future of Support for Society’s Most Vulnerable
Amidst funding restructures, privatisation and the Covid-19 pandemic, the UK’s public services are increasingly undergoing change. From care home homes and emergency services to hospitals and schools, the pressures on the people delivering this care is ever-present.
So what does the future hold for social care and the family support services provided by schools? How will this impact the most vulnerable in society? And what can be done to prevent crises in our social services deepening?
The University of Portsmouth’s Life Solved podcast returns with a new series this April. In the first episode, Dr Bethany Simmonds and Dr Emma Maynard share their insights and perspectives on two vital areas of social support in the UK.
Bethany’s social theory approach to studying clinical decision-making, end of life care and experiences of the ageing population has given her a unique insight into the systemic issues of many care services today. She says that the pandemic has highlighted weaknesses in the healthcare systems of different countries and that poorly structure or opaque systems are putting people at risk here in the UK:
There was just consensus over the number of duplicated services. It is a really a system that doesn’t work for the most vulnerable. Particularly for older people without someone navigating the system for them. It’s devastating – it can mean the difference between life and death
In the podcast Bethany explains her surprising findings when contrasting healthcare systems with different kinds of welfare state. She looked at how waves of Neo Liberalisation in the Global North have played out national policy and discovered that even socially democratic welfare states were relying on outsourced provision of care.
Bethany’s research highlighted that insurance-based systems such as the one in Germany had fewer failings for some of the most vulnerable in society during the pandemic.
Death rates for older people during the pandemic in Germany were a lot less than in the UK and Sweden
I think we are just seeing an unfolding set of more and more complex issues and more mental health needs in schools, which teachers are expected to be able to deal with despite that not being their professional training.
The joint issues created by increased demand for social support and an increase in reporting and monitoring means that teaching staff have been struggling to cope. Emma celebrates the work of schools to support children and families but says that in the face of funding cuts the UK faces more and more people leaving the profession, unable to cope with the increased load on this area of public service.
Whereas both Emma and Bethany agree that supporting workers delivering care with more funding, training and resources is key, Bethany adds that systemic restructures could hold the key to solving our problems. She shares examples of care and support schemes offered in other countries and suggests diversifying this with different kinds of independent charity sector organisations.
You can listen to the full podcast and hear the interviews with Emma and Bethany from Tuesday 26 April 2022.
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Narrator: Welcome to a new series of Life Solved from the University of Portsmouth. In this podcast we’re exploring how research taking place here is changing how we live in and think about our world. As our world moves at pace, the governments, institutions and organisations that serve us rely upon up-to-date research to help make decisions. That’s why in this series we’ll be looking even more closely at how Portsmouth research is playing into current national and world events. We start today by looking at the state of health and social care here in the UK. How is care and decision-making faring in the face of funding changes and private schemes? How does this measure up to what’s happening in other nations, and crucially, what can be done to improve health and social care for everyone in the UK?
Bethany Simmonds: We should be moving away from these large scale organisations that are sort of unaccountable, paying very low wages to staff. The quality of care is very low.
Emma Maynard: We know that all the social needs have increased dramatically during COVID and schools will be dealing with that day in, day out.
Narrator: Meet Dr Bethany Simmonds, a Senior Lecturer in Sociology here at the University of Portsmouth. Her interest in health, wellbeing and care in later life started in 2007 with her PhD. She’s studied end of life care and clinical decision-making as well as paramedic care for older people after falls.
Bethany Simmonds: When I moved to Portsmouth, I decided to write it up in a more sociological way, using social theory and thinking about them as case studies as to why the health and social care system wasn't working for older people, rather than looking at individual clinicians' decision making or low level interventions. I was thinking about what can we do in relation to this system actually not working as a whole? We need to think about the ways in which we value or don't value older people in our society, and I think this isn't just about the pandemic, this is happening really before the pandemic and the way social care has not been valued and has not been sort of really looked at with any sort of priority. This type of care is devalued because it's older people that are being cared for. Rationing of health care for older people was going on before the pandemic, and obviously we saw how devastating the rationing became in these exceptional circumstances with the blanket do not resuscitate orders and refusing treatment for over 80s and refusing to take them to hospital as well. These are actually practices that are against human rights, and you've got to question what sort of society are we if we are letting these practices take place to those who have worked their entire lives and contributed to society and have retired, and then we treat them with no care or no respect.
Narrator: Even before the pandemic shone a light on weaknesses in care systems, Bethany had noticed inequalities for older people. When looking at the processes and experiences of care after a fall, Bethany spoke with paramedics, families and clinicians. She found that fragmented support systems could often compromise quality care.
Bethany Simmonds: Consultants found it very difficult to navigate the system. You know, when discharging older people,there was a myriad of organisations, charities as well as private organisations, as well as families and some public sector organisations, so they're trying to sort of negotiate these duplicated services that all have different contact details, all have different criteria that makes them eligible. And you almost need a degree in that to navigate the system. It's just and it's constantly changing. There was just consensus over the number of duplicated services, the tight criteria that makes people eligible for each of those services, and actually the fact that the ones that really need care the most vulnerable, the most complex - I mean, maybe they might have quite often dementia and they might have complex care needs - They're the ones that aren't eligible for some of these services and get stuck. So it is really a system that doesn't work for the most vulnerable, particularly older people without someone who's actually navigating the system for them.
Narrator: And the life impacts are very real for those who are less able to navigate poorly structured or opaque systems.
Bethany Simmonds: It's devastating. I mean, it can be the difference between life and death, as we've seen in the pandemic, the most vulnerable, are at most risk. And if people are delayed in discharge for a significant period of time, then their health quite often deteriorates very quickly. Quite often the public think hospitals are the safest places for people to be. But actually, clinicians think they're the most unsafe because if you're stuck in a bed and you're not moving, you're more at risk of acquired hospital infections, actually it's really risky. Your physical health deteriorates in terms of your leg strength and your ability to move around, be independent. And then you have to go into maybe some set up where you can have some physiotherapy and sort of get strong again. It's really not good that the most vulnerable people are sort of in these positions.
Narrator: Bethany is also author of “Ageing and the Crisis in Health and Social Care: Global and National perspectives” She was keen to find out how waves of privatisation had impacted the health systems of other countries, and to contrast their results with the UK:
Bethany Simmonds: I actually contextualised what's going on with you in the UK, with other countries and compared them with these two other archetypal welfare state systems. So the two countries I chose were Sweden and Germany. And Sweden has, you know, typically a Scandinavian type of social democratic type of welfare state. And then Germany has a corporate welfare state, which is linked to insurance schemes. It's very heavily insurance based.
Narrator: You might think that these contrasting approaches wouldn’t have much in common on a systemic level, but what Bethany discovered was quite surprising.
Bethany Simmonds: The waves of neo liberalisation in the global north have actually affected these welfare states in different ways. But they both have become privatised in different ways. Particularly Sweden, which is the most sort of surprising, I guess, people consider that to be the gold standard in terms of welfare state provision, but they have actually outsourced their social care to these large conglomerate organisations, as well and have had many scandals, same as the UK actually in relation to social care provision for older people. So it was interesting to see actually that really Germany was even though it's actually provided and has a insurance based system, it's actually provided by the charity sector. So the social care for older people is actually not necessarily provided by these large private organisations as they are in Sweden and in the UK. So the death rates for older people during the pandemic in Germany were a lot less than the UK, and Sweden didn't do that well, either.
Narrator: We’ll be back with Bethany in a moment. Dr Emma Maynard is a Senior Lecturer in Child and Family Studies at the University of Portsmouth. She’s also been looking at the provision of care and social services, but from a different angle and for different people.
Emma Maynard: My focus is on the complex lived experience of children and families, especially children and families who experience different forms of disadvantage. And I also work very closely with schools, in research and in practice. I'm a school governor and I've been researching with schools recently about how they are able to respond to the social and healthcare needs of families in both primary and secondary, researching across England.
Narrator: Emma’s focus on family and child needs allows her to observe the impacts of successful or unsuccessful care provision to people, and the impact on their lives. She explains how the current tier system works and why early intervention is so vital to society.
Emma Maynard: Across England, the way in which professionals understand children's needs are through a tier system. So at Tier one, that's all children who are meeting their developmental milestones, and they might have times when they need a little bit more support. But it's all managed between what we call universal services, that's services that see all children all the time. So examples like schools, health visitors, midwives, they will see all of their patients or children, regardless of what level of need they have. Needs at Tier one and Tier two are covered by those daily services, daily contact. Tier two would be a little bit more concerned, but we can still deal with this within those sort of mainstream services. Tier three is usually aligned to what we call early help. And the thing about early help is that it's really not that early. It's often very complex already in order to get any services. Or it might well be that families have had previous instances of help at that level or higher. So early suggests that it's a kind of an emerging problem, and that's simply not the case. My research has shown that, but also lots of other people's research has shown that. And we also know that around 50 percent of families who are seen within the system come back again, sometimes multiple times within five years. Beyond that though, that's when you get to children's social care and they really intervene when there's an immediate concern about risk to children, that could of course, be life threatening. So at the very top level, that's where children might be in foster care or, you know, go through care proceedings of some kind and things are formalised, they're statutory and parents don't have an option whether or not to engage at that point, or at least if they don't, there are consequences of that. Further down the scale it's all about whether families would like support and how we can make that more accessible to people, because asking for help is really hard. We live in an era where there's lots of social judgement about how people are coping. It's a very neoliberalist environment where people are expected to be helping themselves first and foremost. So to ask for help is loaded. And that's really tough. So services work really hard at making themselves accessible.
Narrator: So what is the ideal outcome of care for a Tier 3 child?
Emma Maynard: A child in Tier three, if it's working perfectly, the services will be able to get involved and support the parents to support the child. So it's all about capacity and how capacity is built. We'll be looking at things like self-esteem of the parents, their confidence in how to manage children's behaviour, how they'll understand children's behaviour as an expression of what they're what they are experiencing. So acting out behaviour is usually because of distress, you know, and to meet it with a calm response rather than an angry, stressed out response can make all the difference but of course that stress multiplies over time. And if people haven't had that help at an earlier stage, then you're looking at some very exhausted parents and a lot of risk happens around that exhaustion and other stresses in family lives like financial stress, like relationship breakdown. You know, instances like domestic violence will increase the risk to children tremendously. So in an ideal situation, people would get in at a stage where, yes, it feels stressful and they need help, and that's why they're there. But they have the capacity to engage with that help and to help, you know, things calm down so that they're also left with some strategies for the long term. And we do know that that happens in a lot of cases, and they say 50 percent come back or 50 percent don't, 50 percent continue on their own in a very resilient way.
Narrator: Emma makes a vital point there about capacity. This is the ability a school or agency will have to provide the correct level of support and care to the family. But capacity is exactly the challenge, just as it can be in the examples Bethany mentioned earlier. Emma saw this even more starkly when studying the impacts of Covid-19 on how schools were able to provide for the health and social care needs of families.Emma Maynard: You've got a collateral number of people who’ve had extreme stress and loss but since the baby Peter Connolly case. We do know that referrals to social care have absolutely shot through the roof because professionals have been much more able, skilled on top of referring. But there is a problem with that as well, because it causes much more strain on the system. So they're probably identifying needs now in a way that they weren't before. And that's of course, a positive. But it also means that the system is choked. We just don't have as much power to do anything with, you know, people are absolutely maxed out with huge caseloads and wanting to do more and are unable to because there's always a higher level of risk somewhere else.
Narrator: She says that historic changes in legislation have meant that schools have borne the brunt of supporting families who have been hit hardest by the pandemic as well as other needs identified by social services.
Emma Maynard: The updated versions of the Children's Act. So the 2001 2003 2004 were putting direct responsibility on the shoulders of schools, quite intentionally so that is now there in statute in the last decade. And there are some really good reasons for that because schools see children day in, day out. They work with families over years and as one of my participants said, a phrase that stuck with me, school never closes a case. We have seen over this decade of austerity a massive increase in the complexity of social need, a huge rise in mental health issues and an already established gap between the services that are needed in the services that are provided with adults as well as with children. And so you've got a twofold issue unfolding in schools because they're trying to support whole families, and the impact on the parents is clearly seen in the children as well and vice versa.
Narrator: And in the case of the pandemic, when children were in school less, schools had an even greater need to reach families and overcome the negative impacts of isolation. What’s more, with funding being cut as the social requirement increases, Emma’s warning is plain:
Emma Maynard: I think for everybody in the sector, it's like screaming into a void, really. But you know, we've had some recent statistics out just saying that there is a massive increase in children admitted into local authority care at the same time as early help services have been dramatically cut. You know, it doesn't take a genius to work it out that if we actually help families at an early enough stage to help them stay together, we're going to have far less family distress and ultimately we will save money. But unfortunately, the policy has been to put all the funds into firefighting and not prevent that fire starting in the first place. We are just seeing an unfolding set of more and more complex issues and more and more mental health needs in schools, which teachers are expected to be able to somehow deal with, despite that not being their professional training.
Narrator: If schools are overly relied upon to offer pastoral support as well as education to society without funding, what does this mean for teaching staff?
Emma Maynard: The emotional labour of teachers and school staff is something that really needs to be thought about. I think as a teacher, you do. Obviously, you're in a caring profession and you're seen as a constant and your students do share things with you. So we really need to think very carefully about what support for the emotional labour is going into schools. It's not just about thinking about referrals, it's about who's actually holding this together.
Narrator: So what does Emma think about this trend of depending on people’s capacity, rather than systems, to support the increasing need for social services?
Emma Maynard: I think Everybody's got a maximum capacity of emotional labour that they can carry. And so, you know, they are continuing with it and they manage to continue that with really strong teams, the emotional labour is absolutely massive. And so there needs to be to start with an acknowledgement, but also a way of processing that of enabling those staff to download their concerns, to be able to rationalise that. And we have ways of doing that in other parts of the sector that aren't replicated in schools at the moment, but it's actually something that I'm working on with with schools currently is to develop some ideas around how that might happen better.
Narrator: Let’s look at this capacity issue in later life and care settings. Bethany says the first step to improving them lies in providing better wages to staff delivering care, but it isn’t the only one.
Bethany Simmonds: Some of the recommendations I've made is that we should be moving away from these large-scale organisations that are sort of unaccountable that are paying very low wages to staff. The quality of care is very low. But we also should be diversifying the types of charity sector organisations that offer care for older people because things like home share, which is a scheme that matches older people with younger people and it's intergenerational and that's not commissioned by commissioning bodies because it's seen as a bit risky. But actually, there's no evidence that there's any there's any more risk than any other system. And actually, there's a lot of benefits because the younger person gets like reduced housing costs and the older person gets help with low level personal care. Befriending really sort of shopping and things like that. And we need to be sort of commissioning more of these types of schemes that are much more innovative and the quality of care is that it's much more relational. There's care homes in the Netherlands that try and dissolve these hierarchical types of systems in care homes. And so the staff and the service users are seen as sort of equally involved in the caring experience, so it's much more relational and reciprocal. There's lots of good examples of ways that we could be reconstructing care, especially social care for older people and moving away from these outdated care homes, which just don't work for anyone, really.
Narrator: Emma agrees that looking after the people delivering services is an essential part of creating more resilient systems, but says it doesn’t stop there. She suggests that change needs to take place on a systemic scale in order to relieve the burden on individuals. And she’s already seen some positive changes underway in agencies working with schools.
Emma Maynard: There have been some really excellent developments in the last few years because now referrals are all through one route in each local authority. Everything goes to the multi-agency safeguarding hub or the MASH, as it's known in all local authority areas. And that means that it takes a lot of the guesswork out for agencies about where things should go, and it avoids a lot of drift. So the MASH team will then assess the level of need and decide whether it's a case for early help or higher. And there's very good working relationships between early help and children's social services, so things will be stepped up or stepped down, and people do work together very well. You know, there are very strong relationships in places. I'm not saying it's perfect, but a lot of the participants in my research have said it's really good. You know, they have really good relationships. They do feel that they're listened to and that there are examples of where schools are able to go back and say, look, we really don't feel this is a good time to close a case. So there is really good collaborative working and a lot of positivity between different parts of the sector about the contributions made by their colleagues. The problem is it's a volume issue and it's a lack of resourcing for the level of need that's out there. People are doing the best they can. There's no question of that.
Narrator: So how is the diversity and breadth of family social needs being catered for by schools at the moment? And is there anything we can learn from other nations?
Emma Maynard: One of the things that schools do routinely is to teach, personal, social, emotional education, which does deal with this stuff as a preventative level. Schools are running nurture groups and mindfulness groups and school counsellors who are accessible to their children and young people all the time. So I think there is some truly preventative stuff going on and a wider acknowledgement of mental health stress, particularly in the last few years. I think we're seeing much less stigma, much more normalisation that everybody has levels of anxiety that feel uncomfortable at times. And that's OK. The emphasis on a healthy lifestyle diet exercise, the gut brain axis, the stuff we're learning about in ways that are accessible and publicly disseminated. So I think that is a massive win. And, you know, perhaps one of the solutions is to try and capitalise on that more and more because we are a resilient species, we are able to rise to. This is just there seems to be a gap in the middle where it's a bit beyond that mainstream stuff. And it's before the really high level specialist services get involved. We've got a huge gap and that I think that's really the nub of it. Looking internationally, in children and families work, a lot of really good practices come from Australia. So there's a programme called "Triple P": Positive Parenting Programme, that came from Australia and also "signs of safety", which is a strength based approach to understanding family needs. We can also really look at the Scandinavians because they frequently have children reporting a higher level of happiness. And what we also see in Scandinavia is they have much more of a play based curriculum. So colleagues and early years in the UK would be very well versed in this because play is what children really need for their learning and development. So in terms of resilience, learning, mental wellbeing and everything else, a lot of it comes back to us needing to have more time to play throughout our schooling.
Narrator: Back to Bethany now. How is it possible to make the funding that is available for care most impactful for the public? Bethany thinks that although the government has taken some first steps towards reconstructing our care system in the UK, funding won’t be impactful unless it goes to the right places.
Bethany Simmonds: They've brought in integrated care systems. They've committed funding to social care, but it's not just about how much money you spend, it’s how you spend it? It's how you spend it. And if, if, if the profits are being creamed off and sort of given to stakeholders instead of being re-invested in the system, it is actually not good value for money for the public purse.
Narrator: But money aside, she says more needs to be done with regards our attitudes to older people here in the UK.
Bethany Simmonds: Everyone is hopefully going to reach later life. And so if we take away the rights of older people, we're taking the rights away from ourselves when we reach 80. And is that what we want for ourselves? It's a myth that you can pitch one generation against the other because ultimately, if we're lucky enough, we're all going to reach later life. So yeah, I think we need to really think about that as a society.
Narrator: In her next project, Bethany would like to look at the experiences of families who have lost older people during the pandemic, as a social history and resource, but also as an analysis of the decision-making that reveals our true priorities as a society.
Bethany Simmonds: I'm interested to capture their experiences and think about ways in which we can protect this from happening in the future. These types of ebbing away of people's human rights in these extraordinary times.
Narrator: Two perspectives on two vital sectors of our society. Whilst school and agency social care may face different challenges to that of healthcare and care home provision – the youngest and oldest in our society are our most vulnerable and it is these people that are let down by mismanaged funds, opaque systems, duplicated services and the consequences of over-burdened and under-trained staff. However, the alternative models, schemes and research on the table can bring hope, if we are able to reassess our systems and values to meet the needs and pressures of a modern society. You can find out more about research at the University of Portsmouth on our website port.ac.uk/research. We’ll be back again next week. Follow this podcast on your favourite app so you don’t miss it. And if you liked this episode of Life Solved, why not share it with a friend and start a conversation. See you next time.