Flourishing

“The goal of a reimagined system of care and support is to enable all humans to flourish. Care can sometimes be reduced to tasks, focusing on our physical needs of eating, drinking and going to the toilet. Sometimes safety from harm overrides all other considerations. This sets the bar too low.”

Archbishops’ Commission on Reimagining Care [1]

Our current ‘care system’ is a safety net, not a springboard, where we define our purpose in terms of ‘keeping people safe’, not supporting people to flourish, and where too often our practice focuses on keeping people alive, not ensuring that people thrive.

As Hilary Cottam observes, “our welfare state might still catch us when we fall, but it cannot help us take flight.” [2]

Safety net

By its very definition, a safety net is there to save us when times are hard, things are tough, life is precarious.

To catch us when we fall.

Describing the purpose of social care in this way perpetuates our medical model approach of fixing people, and our charity model approach of rescuing “those who are vulnerable”. It frames people who require assistance to live their lives as helpless. In need. And it locks us in to thinking of social care as a crisis response service, here to ‘look after’ and ‘protect’ ‘the vulnerable’, or to “get people back on their feet”, “reduce dependency” and “regain or retain skills to enable them to manage with minimal or no support”.

Those last few phrases come straight from the narrative of ‘strengths-based’ approaches.[3] While such an approach *should* be about flourishing lives, too often it is reduced to an attempt to ‘manage demand’ and ‘signpost’ people elsewhere.

And when we talk of ‘prevention’ in terms of “preventing the development of needs for care and support” we place social care as something there when all else has failed. ‘Care’ for ‘broken’ people, after ‘carer breakdown’. Services that swing in once there is a problem, to pick up the pieces and prevent things getting worse.

These narratives overlook the overall aims of independent living – equal rights, choice and control, inclusion, participation, and the vital role of social care in enabling them. They perpetuate instead notions of self-sufficiency and individualism that disregard the importance of relationships and belonging, and the inter-dependency and reciprocity that characterises genuinely flourishing lives.

As such, people’s basic human desire for love and connection is largely ignored in care and support plans and ‘packages’ that focus on meeting ‘personal care needs’ and keeping people alive – not offering or sustaining reasons to live.

A safety net riddled with holes

The dominant social care rhetoric repeated by ‘sector leaders’ and echoed by the media focuses on what is missing. On hospitals having to “keep patients” on wards for longer “because there aren’t enough care beds and homecare packages available”. On “chronic staffing shortages”. “Record social work vacancies.” The “lack of providers”. The “gaps in social care funding”. The “vulnerable older and disabled people [falling] through a safety net riddled with holes.”

It’s a narrative that highlights the “absolute crisis” facing the ‘system’. The “rising demand”. The “greater complexity” and “increased acuity” in “presentations”. The “threat to vital services for vulnerable residents.” The “soaring social care costs” that place “an unsustainable burden” on councils.

While we wait in vain for a ‘fix’, we invest in “strengthening our front door.” ‘Navigating’ people to “other organisations (e.g. in the voluntary sector) that might be able to provide assistance”. Re-directing “those considered to have a low need”. Reporting ‘performance’ in terms of the number of “clients” we have “signposted to other services”.

And we cope by gatekeeping. As Mark Smith notes, “the logic is plausible. By making it harder to access services, we can use what little resources we have supporting those that need it the most. “Come back when you’re worse”, we say.” [4]

There are of course multiple issues with all these responses.

As I’ve noted before, this ‘social care is broken’ rhetoric is exhausting and exhausted. [5] It perpetuates the framing of social care as a ‘safety net’ to ‘protect our most vulnerable’. As ‘services’ and ‘settings’ and ‘beds’ and ‘packages of care’ for ‘others’, who it implies are ultimately to blame for all these problems anyway. It’s a narrative about sustaining a ‘sector’, told by the sector, not about investing in communities and wellbeing and good lives.

Funding the ‘joining’ but not the dots means that we’re investing in the ‘navigators’, but not in the “community resources” they’re employed to connect people to.

While we may record handing people a leaflet or dictating another number to ring as a satisfactory conclusion to our ‘front-door process’ (‘no further action’, ‘involvement ended’, ‘case closed’, job done), we’re effectively saying off you go, you’re on your own, start again. And how many people don’t, can’t, start again?

“When someone gives me a telephone number as a means of access and tells me to ring it myself, I don’t ring it. They don’t know about the anxiety. That you’re already overwhelmed in that space and then to have to do that and explain it all again and do it all again. It’s like, just leave it. I’ll just sit in this problem. I can’t be bothered.”

Issachar John [6]

Our impenetrable forms mean time is tangled up in the bureaucracy and complexity of our ‘computer says no’ system. Time we could and should be spending alongside people, listening liberating loving connecting caring.

“If I have any regrets, it’s every single minute that I didn’t spend holding his hand because I had to go and write an email, I had to go and make a phone call. Having to fight the system that should be there to catch you when you fall but feels when you’re going through it like it’s there to catch you out.”

Kate Garraway [7]

This approach has an “incalculable human cost”, and a significant financial cost too, because “systems that exclude by design or default are extremely expensive.” [8] When people do come back when things are worse, things are worse! And options are reduced. Support is more reactive. More intensive. More restrictive. More expensive.

But perhaps the main issue is that we’re ignoring the main issue. We’re blithely overlooking the fact that our current ways of working aren’t working. That signposting and gatekeeping and ‘managing demand’ actually contributes to rising demand greater complexity increased acuity soaring social care costs and record vacancies.

We’re not admitting that we’re propping up a system that is “mostly focussed on time and task, life and limb care [that] isn’t something any of us wants for ourselves or our loved ones” [9] – summed up succinctly by “someone very sage” who once told Angela Catley that “social services spend a huge amount of time and effort trying to stop me having what I didn’t want anyway!” [10]

We’re not listening to the people who are living this ‘experience’, who are too often absent from conversations and decision making. Impacted most. Mostly ignored.

And in our obsessive focus on what’s missing and what’s wrong, we’re overlooking what we have, and what is strong.

Abundance

When we view ‘care’ in terms of ‘packages’ and ‘hours’ and ‘settings’ and ‘beds’, resources are finite, and our narrative is inevitably one of scarcity.

But maybe, just maybe, “the gap is actually in the definition and not in ‘provision’” [11]

In our current definition, ‘care’ is a service and – as John McKnight observes – “the central assumption is that service is a unilateral process. I, the professional, produce. You, the client, consume.”. But if we shift to viewing care in terms of relationships, then we recognise and value people as ‘assets’, not ‘demand’, and ““you need me” becomes “we need each other””. [12]

Instead of highlighting what is absent, we notice and build on and invest in what is present.

And instead of assessing and redirecting, we focus on understanding and connecting.

This recognition and appreciation of abundance moves us naturally to thinking in terms of people and communities rather than services and institutions. Instead of focusing our attention on how we sustain a ‘care sector’, we think instead about how we ensure a sustainable care and support infrastructure. A “web of relationships and support in our local communities that we can draw on to live our lives in the way that we want to, with meaning, purpose and connection, whatever our age or stage of life.” [13]

Flourishing

Hilary Cottam writes that “this idea that the work of caring for one another is core to our humanity and human wellbeing was well understood by our ancestors.” She references ‘eudaimonia’ – Aristotle’s concept of ‘flourishing’. That “we need support to grow and develop and we need a sense of meaning,” and that “for Aristotle, this meaning comes through collective participation… tending to one another and the wider infrastructure that shapes our world is what enables us to flourish”. [14]

We thrive through participation and being needed. Having purpose and meaning. Caring and feeling cared about.

We flourish through interdependence.

However, “in the West this understanding of human flourishing has gradually unravelled”, as the “ruthless quest to maximise individual material gain” means ‘work’ and ‘care’ are separated, and the “messy business” of ‘caring’ is “outsourced, placed elsewhere, out of sight”. [15]

“Hidden”, “economically inactive” carers, “suffering under the burden of looking after loved ones.” “Giving up work to care.”

And industrialised, institutional, Chronos time ‘care’, ‘delivered’ by the clock, where human ‘messiness’ is tidied neatly into ‘visits’ and ‘schedules’ and ‘settings’, and where underpaid workers maintain isolated individuals.

You’re unlikely to flourish in a world where caring – and requiring some assistance to live your life – means you’re exhausted by uncertainty and juggling and fighting for recognition and understanding and support.

You’re unlikely to be able to be or become who you want to be, or to do the things that matter most to you, when you’re forced to fit in to institutional boxes and priorities and schedules.

You’re unlikely to thrive in a ‘system’ that denies your human needs for love and connection and meaning and purpose, and even denies that you are human.

“When you’re not perceived by other people and your social needs are so deprived, so povertous, there’s nobody, it’s just you, you don’t actually know that you exist.”

Alexis Quinn [16]

To ensure we all flourish, we need to stop segregating people and people’s lives, and focus instead on creating the conditions we all need to thrive.

“When a flower doesn’t bloom, you fix the environment in which it grows, not the flower.”

Alexander Den Heijer [17]

Springboard

“Just as trees stand tall in their individual beauty by entwining their roots with one another, so we as individuals, communities and nations only fully reach our potential within ecosystems of care and support.”

Hilary Cottam [18]

In our safety net approach, ‘care’ is a service. A destination. An ending.

A springboard, in contrast, is about beginnings. Opportunities. Possibilities.

The Equality and Human Rights Commission ‘From safety net to springboard’ report published back in 2009 describes a vision “of an infrastructure of care and support which acts as a springboard by promoting and sustaining the capabilities of individuals and their families to maximise control over their own lives, to participate and contribute socially and economically, and through doing so improve their well-being and prosperity and that of the wider community and economy.” [19]

In this approach, “social care is not an end in itself but the means to a better life. [It is] about supporting active citizenship. It is built on the bonds of mutual interest and inter-dependency that define our common humanity, acknowledging that most of us will give and receive care and support during our lives.” [20]

In this approach, care is a relationship – not a task or a transaction, and support is sourced – and resourced – in communities.

In this approach, we focus not on ‘what’s the matter’, but on what matters most to people and what makes people matter most.

Not on ‘what do you need’, but on being needed.

Not on what’s missing and what is or could go wrong, but on what is present and what is possible and what is strong.

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References

[1] Care and Support Reimagined: a National Care Covenant For England, Archbishops’ Commission on Reimaging Care, January 2023

[2] Radical help, Hilary Cottam, Virago, 2018

[3] Words that make me go hmmm: Strengths-based, Bryony Shannon, Rewriting Social Care, 11 December 2021

[4] Eligibility criteria – what if we just turned them off?, Mark Adam Smith, Changing Futures Northumbria, 10 August 2022

[5] Time for change: the language of social care reform, Bryony Shannon, Rewriting Social Care, 24 September 2022

[6] Your care and support: Doncaster, Adult Social Care Local Account 2024, Adult Social Care Making it Real Board, 2024

[7] Kate Garraway: Derek’s Story, ITV, 2024

[8] Welfare 5.0: Why we need a social revolution and how to make it happen, Hilary Cottam, UCL Institute for Innovation and Public Purpose, September 2020

[9] Living good lives in the place we call home – An outline programme for the next government, Social Care Future, February 2024

[10] Mavis and Meena – social care abundance or deficit? Angela Catley, Community Catalysts, 30 May 2023

[11] Mavis and Meena – social care abundance or deficit? Angela Catley, Community Catalysts, 30 May 2023

[12] No more throw-away people: the co-production imperative, Edgar Cahn, Essential Books, 2000

[13] How to build public support to transform social care: a practical guide for communicating about social care, Neil Crowther and Kathryn Quinton, In Control for #socialcarefuture, April 2021

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

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

[16] When you’re not perceived by other people…, BBC Newsnight, Twitter, 27 March 2024

[17] “When a flower doesn’t bloom, you fix the environment in which it grows, not the flower”, Alexander Den Heijer, Good Reads

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

[19] From safety net to springboard A new approach to care and support for all based on equality and human rights, Equality and Human Rights Commission. 2 February 2009

[20] Care and Support Reimagined: a National Care Covenant For England, Archbishops’ Commission on Reimaging Care, January 2023