Chronos time

“Care is not an activity that can happen by the clock… Care belongs in the world of Kairos time (measured by flow and connection) as opposed to Chronos time (the industrial time measured by minutes and deadlines). Care is not the same as cure – yet it so often seems we have confused these categories. This is why our care systems ‘think’ in terms of an activity that is costed, rationed and meted out in response to a specific need or life moment, as opposed to an ongoing human activity.”

Hilary Cottam [1]

Care belongs in the world of Kairos time, but Chronos time undoubtedly dominates the world of statutory social care. Hours and minutes. Schedules and rotas. Agendas and deadlines. Measurements and targets.

In this first of a series of three blogs on social care and time, I’m focusing on what the language of social care reveals about this dominance of Chronos time. The second blog will explore what social care in the world of Kairos time looks like, while the final blog will reflect on the way we talk about time in relation to social care reform.

Fast-paced environments

When I wrote my blog post about the language of social work job adverts, one of the things that really struck me was the emphasis on speed.

• “It is a fast-paced team, and you don’t hold cases for long.”
• “You will ensure that all cases are progressed efficiently through the system within this fast-paced environment.”
• “We want you to think and act fast to support the most vulnerable people in our population.”
• “The team works in a fast paced, highly pressurised environment.”
• “[We provide] an initial screening assessment aimed at resolving lower level care needs as quickly as possible.”
• “This is a large, fast paced locality team which would best suit somebody who thrives working in busy environments [and] has excellent time management skills”
• “We have embraced agile working and offer flexible arrangements to work from home or the office to make best use of time.”

Fast. Busy. Quick. Efficient.

The language of transactions. Production lines. Sorting offices.

Standardised. Managed. Linear. Controlled. Quantified.

The social care ‘industry’.

Industrial time.

Busy teams

Our teams are busy.

• “You will be working within a busy team and be expected to work at pace while maintaining a high standard of practice.”
• “This is a busy team with a fast throughput of work.”
• “It’s a busy team and the nature of the work is high paced”.

Research suggests that social workers spend close to 80% of their time on admin, while only 20% of their time is spent working directly with children and families [2].

So busy screening triaging assessing processing purchasing placing recording reviewing reporting.

Too busy for people.

“I spend so much time recording and writing reports that I feel like I’m in an admin role rather than a social worker. It’s horrible and not what I signed up for. I get reprimanded if I choose to prioritise time with clients over recording.”

British Association of Social Workers [3]

Waiting

Despite this pace, this industry, the queues are growing.

Six hundred people a day are joining waiting lists to be assessed for care and support in England. One in four have been waiting longer than six months. In all, 542,002 people are waiting for assessments, reviews or for services or Direct Payments to start [4].

Over half a million people, waiting.

And even though the statutory guidance states that “it is critical to the vision in the Care Act that the care and support system works to actively promote wellbeing and independence, and does not just wait to respond when people reach a crisis point” [5], we do wait.

Too busy reacting to be proactive.

Too busy responding to crises to prevent them.

We won’t wait for long though. If you ‘refuse to engage’, or you ‘fail to respond’ or you don’t ‘comply’, we’ll remove you from our waiting lists and close your case.

Immediate needs and quick fixes

“Care decisions are often made quickly and at a time of crisis.”

Department of Health and Social Care [6]

We work in the moment, in the present time – responding to crises, to new requests for support, to ‘unplanned reviews’. We focus on ‘immediate needs’, prescribe sticking plaster solutions from a narrow menu of services and move on as quickly as possible to the next ‘case’.

There’s no sense of any connection or continuity. No ongoing conversation or collaboration or curiosity. Just a series of transactional starts and stops.

Episodes

“The health and care system too often treats discrete episodes of mental or physical illness rather than considering a person’s care needs holistically.”

Department of Health and Social Care [7]

Care is described – and measured – in ‘episodes’. Short-term. Time-limited. Discrete. Disconnected. “Episodes of social care support”. “Brief episodes of care”. “Planned and unplanned hospital episodes”. “Episodes of respite care”. [8]

We dip in and out of people’s lives like we’re watching just a couple of shows from a multi-season television series or reading only one or two chapters of a novel. No chance to get to know the characters, understand the setting, interpret the narrative, or follow the plot twists (though we’re pretty good at making assumptions about what should happen next without knowing the full story).

Time and task

‘Care’ is prescribed and commissioned and ‘packaged’ and ‘delivered’ in hours and minutes. Rotas and schedules dominate, and time is money. “A time and task model of care where both clients and staff are reduced to numbers, activities and timing on schedules”. [9]

People working in social care juggle and justify time.

“We often only have 15 minutes in someone’s home. They expect more from us but we don’t have the time. If we put in extra time we don’t get paid for it. They want to talk, they miss their family. They cry, they beg us to stay. It’s challenging and very emotional, especially the last two years. You want to help but there are so many restrictions on time.”

Latif Choudhray [10]

“There are times when they [care workers] might not make it because they are so busy… When they do get there they’re in such a hurry that they can’t complete the time they’ve got allocated to spend with my parents, so they might cut things short.”

Michael Robinson [11]

People drawing on care and support juggle and justify time.

“My life got split up into chunks. How long will it take me to have a shower? How long do I need to get dressed? How long for food preparation? That is not what I want my life to be about. I find myself in the position quite regularly where I have to think, “Well, I only have two hours left this week, so do I want to do food shopping, have another shower or go and meet up with a friend?” It is quite a hard place to have to live your life when you have to quantify the things you want to do into a small number of hours a week.”

Anna Severwright [12]

Zero hours and part-time work

Almost a quarter of all the people who work in adult social care are employed on zero-hour contracts, rising to over half of domiciliary care workers. Half the workforce is part-time, rising to 87% of personal assistants. Hourly rates of pay for care workers are amongst the lowest of the economy in general. [13]

In theory, a flexible career choice and a fluid workforce, ebbing and flowing to suit the lives and needs of people working in, and drawing on, care and support.

In reality, an insecure and inflexible option for social care workers and for the people they support.

Visiting times, mealtimes, and bedtimes

“Told them I don’t like going to bed at 7 o’clock at night. Carers come at 8.30am – 9am in the morning so I asked if they could come later, they said ‘No’ because everyone has a set time and it can’t be changed.”

Care Quality Commission [14]

Set times pervade the lives of so many people who draw on care and support. Home care is timetabled – typically four calls a day. Visiting hours are set. Mealtimes are fixed, and often the menu is too. Bedtimes are generally early, too early.

“When the agency came to do my assessment, they had no problem in doing what I needed for my morning call at the time I wanted. But for the evening call they said the latest call was 8pm, which would mean going to bed early every night. I reluctantly accepted this.”

Jennifer Pearl [15]

Living (barely) by the clock.

Days and weeks scheduled to suit providers, not people.

No choice.

No control.

No life.

Free time

“The provider had asked people what activities they wanted to take part in. People fed back they would like to go to the cinema, theatre, the seaside, shopping and going out for a meal. There was no evidence from the daily notes that these activities had taken place”.

Care Quality Commission [16]

The Care Act is clear that wellbeing – which local authorities have a duty to promote – includes participation in recreation, personal relationships, and people’s contribution to society.

Friendships are started and sustained in ‘free time’. Love sparks and blooms. It’s time for adventures, for exercising body and mind, for dreaming, and becoming, and remaining, and returning.

Time for doing the things that matter to us.

Leisure time, and the opportunity to fill it, is not just a nice to have, an optional extra. It’s essential to citizenship and human rights and ordinary, equal lives.

And yet care plans and care ‘packages’ still focus on survival, and rarely on reasons to stay alive. On ‘activities of daily living’ but not the activities that make life worth living.

“People were not supported to participate in their chosen social and leisure interests on a regular basis. People consistently told us they were bored and wanted to go out and do more. One said, “I don’t do very much””

Care Quality Commission [17]

And despite the Care Act statutory guidance clearly stating that “local authorities should consider whether the carer has leisure time, which might for example be some free time to read or engage in a hobby,” [18] for unpaid carers free time is often non-existent. Research prior to the COVID-19 pandemic found only 8% of carers felt that they had been able to take sufficient breaks, [19] 40% of carers hadn’t had a day off for more than a year, and a quarter hadn’t for more than five years. [20] More recent research found 72% of carers had not had any breaks from their caring role during the pandemic. Of the carers who did have a break, a third used the time to complete practical tasks or housework, and a quarter to attend their own medical appointments. [21]

Annual reviews

The Care Act statutory guidance sets out an expectation that care and support plans will be reviewed “no later than every 12 months.” [22] These annual reviews should be an opportunity to reflect on what is working, what’s not working and what might need to change, to make sure plans are kept up to date and relevant to the person’s needs and aspirations and help prevent people entering a crisis situation. [23]

In reality though, these proactive, ‘planned reviews’ are continually pushed down the ‘to do’ list as new requests for support and hospital discharges and safeguarding concerns and provider ‘handbacks’ and ‘breakdowns’ in informal care arrangements and complaint responses and ‘DST meetings’ and panels and paperwork take priority.

‘Unplanned reviews’ in response to crises take precedence over ‘planned reviews’ and crisis prevention.

And when annual reviews do take place, too often they’re a high stakes, anxiety inducing interview controlled by an unfamiliar professional and dominated by the threat of hours being cut.

“A lot of us who use social care fear our hours being cut. It makes me feel sick to think that my review is coming up because it is so out of my control, and those hours could be cut. I know many people who have had their hours cut, often by up to a third, just like that. That is a third less life that that person can effectively be getting on with and living.

Anna Severwright [24]

Measuring time

We measure what we do in days and hours. Minutes and deadlines.

• Percentage of assessments completed within 28 days.
• Percentage of annual reviews completed on time.
• Proportion of older people (65 and over) who are still at home 91 days after discharge from hospital into reablement/rehabilitation services.
• Number of homecare hours delivered.

Electronic call monitoring systems provide assurance based on time.

Quantitative measures to demonstrate we ‘got the job done’.

Quantitative measures that add numerous tick boxes to our forms (keeping social workers busy).

Quantitative measures that add charts and tables and graphs to endless reports to evidence ‘performance’ (keeping team managers busy).

Quantitative measures scrutinised and disputed and manipulated (keeping performance teams and senior leaders busy).

Quantitative measures that give no indication of the experience and wellbeing of people and families.

Measuring outputs, not outcomes.

Quantity, not quality.

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It’s clear that Chronos time still dominates – and perpetuates – our industrialised, institutionalised approach to care and support. Processes and transactions and measurements rule. Care is ‘packaged’ and ‘delivered’ in hours and minutes. Workers are reduced to robots, and people seeking or drawing on support to widgets.

All time is accounted for.

All eyes are on the clock.

A race against time, which nobody wins.

It doesn’t have to be like this.

In my next blog, I’ll explore what social care in the world of Kairos time looks like.

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References

[1] A radical new vision for social care: How to reimagine and redesign support systems for this century, Hilary Cottam, The Health Foundation, November 2021

[2] 80-20 campaign final report, British Association of Social Workers (BASW), 17 September 2018

[3] 80-20 campaign final report, British Association of Social Workers (BASW), 17 September 2018

[4] ADASS Survey: People Waiting for Assessments, Care or Reviews, Association of Directors of Adult Social Services, 4 August 2022

[5] Care and support statutory guidance, Department of Health and Social Care, 16 June 2022

[6] Care and support statutory guidance, Department of Health and Social Care, 16 June 2022

[7] People at the Heart of Care: adult social care reform, Policy paper, Department of Health and Social Care, Updated 18 March 2022

[8] Short and Long Term (SALT) Data Return 2021-22 guidance, NHS Digital, 8 March 2022

[9] Radical home care: How self-management could save social care, Ruth Hannan, RSA, October 2019

[10] Desperate, exhausted and poorly paid: Workers lift the lid on Greater Manchester’s crumbling social care, Charlotte Cox, Manchester Evening News, 17 January 2022

[11] Care workers forced to cut short home visits or be left out of pocket, Melissa Viney, The Guardian, 29 January 2019

[12] Health and Social Care Committee Oral evidence: Management of the coronavirus outbreak, HC 206, House of Commons, Tuesday 9 June 2020

[13] The state of the adult social care sector and workforce in England, Skills for Care, October 2021

[14] Profad Care Agency Limited Inspection report, Care Quality Commission, 11 July 2022

[15] What time do you go to bed? Jennifer Pearl, Think Local Act Personal, 18 November 2021

[16] Gables Care Home Inspection report, Care Quality Commission, 14 July 2022

[17] L’Arche Bognor Regis Bethany Inspection report, Care Quality Commission, 18 July 2022

[18] Care and support statutory guidance, Department of Health and Social Care, 16 June 2022

[19] Carers at breaking point: Making the case for carers’ breaks in England, Carers UK, August 2019

[20] Breaks or breakdown Carers Week 2021 report, Carers UK, June 2021

[21] Breaks or breakdown Carers Week 2021 report, Carers UK, June 2021

[22] Care and support statutory guidance, Department of Health and Social Care, 16 June 2022

[23] Care and support statutory guidance, Department of Health and Social Care, 16 June 2022

[24] Health and Social Care Committee Oral evidence: Management of the coronavirus outbreak, HC 206, House of Commons, Tuesday 9 June 2020