Geographies of Care

Space, Place and the Voluntary Sector

Christine Milligan

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351744249
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

This title was first published in 2001. As care services in Britain have moved from institutional to community-based environments, there has been a simultaneous shift in those agencies concerned with the provision of such care and support. this new environment of care is a complex one, involving numerous different actors and agencies that operate across various different spatial and organizational levels of the policy process. The implementation and success of care policies depend in part on the inter-relationships between these various players. This book examines these inter-relationships, illustrated by an in-depth empirical study of policy makers and informal care providers concerned with the frail elderly in Scotland. Taking the voluntary sector as a lens through which these inter-relationships are explored, it analyzes how voluntary support is affected by differing local contexts of care and what this means in terms of locally based care outcomes.

1 Introduction

Since the 1970s, and more evidently throughout the 1980s and 1990s much emphasis in the UK has focused on the way in which successive governments have attempted a retrenchment of publicly provided social welfare. A major change effected by this restructuring has been a shift in the location and mode of the delivery of care to service dependent populations - that is, the frail elderly and those experiencing mental, physical or sensory impairment. One element of this shift has been a move away from the prevalence of publicly provided services located within large, centralised institutional environments towards domiciliary and small community-based sites of delivery.

Hand in hand with the changing locus of care has been a change of emphasis in the mode of service delivery. Care is no longer viewed as the prerogative of public services. Rather, there is growing consensus amongst policy-makers that the informal sector (defined as comprising voluntary/non-profit organisations, the private sector and informal carers: Cm. 849, 1989) could and should play a key role in the provision of social and welfare services. Legislation from the late 1980s has thus sought to promote a mixed provision of care to include voluntary, private and informal care supports. Such options are seen as offering flexible and cost effective ways of delivering social and care services within local communities. As a consequence, provision is said to be breaking away from the ‘binary choices’ of public or private sectors, toward the development of a social market that incorporates the voluntary/non-profit sector (Amin et al, 1999).

Within this changing environment of social welfare, there are a number of issues that merit research that is sensitive to the ways in which social processes related to welfare reform operate in specific places. Of particular relevance, here, has been the call for research that explores the extent to which recent developments in social welfare have either improved or constrained the lives of specific groups of people in specific regions (see for example, Pinch, 1997). This book aims, in part, to explore these issues by considering one facet of the changing environment of social welfare; that is the restructuring of care provision to service dependent populations in the UK.

Geographers’ interest in welfare reform and deinstitutionalised care is not new. It is evident in work that spans more than two decades, from Wolpert and Wolpert’s (1976) early study of the relocation of mental hospital patients, through to more recent studies by Dear and Taylor (1982), Dear and Wolch (1987), Smith and Giggs (1988) and Kearns and Smith (1994). These works have focused largely on the exclusionary and locational experiences of deinstitutionalised individuals and the spatial implications of the new geography of care practice. Few, however, have sought to examine the role of non-statutory agencies in this process. Those geographical studies on voluntarism that do exist have tended to focus either on the role of the voluntary sector in regional economic growth and decline (e.g. Wolpert, 1977; Wolpert and Reiner, 1981), or the uneven nature of the spatial distribution of voluntary organisations (e.g. Wolch and Geiger, 1983, 1986; Wolch, 1989, 1990). Such studies make little connection between the impact of geographical variations in informal care supports on the lives of service users, and the ways in which voluntary supports can influence, and be influenced by. differing local contexts. Indeed, it is only in the last few years that a small body of geographical work has emerged whose concern has been to examine the place of the voluntary sector in the lives and experiences of community-based service users (see for example Milligan, 1996; Brown, 1997; Parr, 1997; Kearns, 1998).

With this in mind, the book aims to make two key contributions to our understanding of care reform. Firstly, it goes some way toward redressing gaps in the geographical analysis of the informal sector by examining how deinstitutionalised care is effecting changes in the interrelationships between public and informal sectors. These changes are viewed through the lens of the voluntary sector. The book sets out to explore the collective experiences of voluntary organisations in the process of care restructuring, to reveal how this restructuring is manifest within two different spatial environments in Scotland. The first of these sites is the urban-based locality of Glasgow City in central Scotland; the second is the semi-rural locality of Dumfries and Galloway in south west Scotland. Whilst urban/rural issues form one of the spatial dimensions discussed, the book also draws attention to additional geographical factors that are of equal importance in understanding how care restructuring is manifest at local level. The changing environment of care provision in Scotland has been further complicated by the implementation of the Local Authorities (Scotland) Act of 1996. The Act, which fused together district and regional councils into one single tier of local government, resulted in a re-drawing of local authority boundaries in Scotland. As a consequence, some local authorities have experienced major change. These factors are shown to have had additional implications in terms of the spatial outcomes and experiences of care restructuring within localised contexts.

Theorists of care highlight the importance of the interconnectivities and interdependence that characterise care as a relationship (see for example, Gilligan, 1982; Tronto, 1993; Daly and Lewis, 2000). In Daly and Lewis’s terms, such relationships are defined as “the activities and relations involved in meeting the physical and emotional requirements of dependent adults and children, and the normative, economic and social frameworks within which these are assigned and carried out” (2000, 285). So care is seen as involving labour, obligation and responsibility with costs that are both financial and emotional. Such care extends across both public and private space. Yet such interconnectivities are not uniform over time or space, and local conditions can interact with broader trends to produce specific geographies of care. The influence of space and place in shaping care outcomes is an issue that is all too often ignored by care theorists. This book seeks to go some way toward redressing this omission by examining how such variations act to influence evolving patterns of formal and informal sector care in the Scottish context, and hence the experience of care provision.

Four themes, in particular, are explored. First, the book examines the influence of the voluntary sector in the development of social care provision. Second, it considers factors contributing to geographical variations in access and availability of voluntary sector supports and third, it examines the inter-relationships occurring between formal and informal sectors at locality level. Finally, the book focuses attention on the ways in which key agents operating within specific spatial arenas impose their own agenda/interpretation on voluntary action. The outcome of such action reveals a complex spatial manifestation of care restructuring which is seen to be generated at various spatial levels.

Through its focus on informal care provision, the book illustrates how variations in access to informal care can arise as a consequence of political, economic and historical factors that vary both between local authority areas and within them. It, thus, highlights how social welfare restructuring is shaping the ways in which care is made available within different geographical settings. These issues are implicit throughout the analysis of the substantive chapters of the book, and are drawn together more explicitly in chapter eight.

In considering the progression from institutional to community-based models of healthcare, the book moves away from the more traditional focus on bio-medical models of health and illness to examine how social, cultural and political factors impact on experiences of health and healthcare. While recognising the importance of the individual, the book also points to the importance of understanding how decisions are made with regard to care. This points to the need to understand the policy environment within which social care is mediated. While legislation emanates from central government, numerous influences are brought to bear as it is translated and transformed by actors operating at various levels of the policy process - many of which occur within localised contexts. Local authorities, health authorities and the informal sector, for example, play a key role in the implementation of policy at local level. Hence, though action by central government is important - serving as a guideline for interpreting both the spirit and intent of the law - it is only by examining how policy is mediated by actors operating within and across various spatial and organisational environments, that the connections between care policy, and the many local scenes within which it is translated and practiced, can be made.

Any narrative of health and social care restructuring must necessarily take cognizance of those relationships occurring between actors operating at various spatial scales. So, while the book acknowledges the wider social, economic and political context within which change occurs, it is also concerned to examine those relationships occurring at the meso- and micro-levels¹ of the caring process. To enable these issues to be explored within two different geographical settings, the empirical research has been linked through the development of a conceptual framework within which these relationships can be examined. This forms the second major strand of the book. This proposes the basis of a model - the ‘dependency network’ - that seeks to build on wider frameworks of network theory. While these approaches have been employed as a means of interrogating developments within regional and economic geography in recent years, their utility for examining issues of health and social welfare have yet to be explored. Thus, in addition to illuminating geographical issues pertaining to the changing role of the informal sector, the book also seeks to contribute to our understanding of how care restructuring impacts on actors and agents at local level through the development of the ‘dependency network’.

Within any such inter-related framework, it is difficult to understand the whole. The network approach adopted here reflects a need to examine the various influences of actors operating within and across landscapes of care in order to understand how outcomes are manifest within localised contexts. Inevitably, this means that this approach to the examination of care restructuring is, to some extent, deductively driven by the context, in that the wider framework of health and social care restructuring can be said to predetermine those actors operating within the network. Restructuring, however, cannot be viewed simply as a backdrop to the study - in emphasising the role of different actors, it also serves to shape the form of network participation. In this way, relationships within the network can be seen to arise as a consequence of the dynamic process of change. Thus, by examining the outcomes of restructuring from within the network, the book aims to contribute to a wider understanding of the social and spatial influences on the caring process.

The predetermination of actors operating within this conceptual framework has played a pivotal role in the methodological construction of the study. As noted above, the focus of the book is on one particular set of actors - the voluntary sector. While this sector has long played a role in British welfare (Taylor, 1992), the magnitude and importance of key relations between the voluntary sector and the state have altered significantly in recent decades. Legislation defining the restructuring of health and social care to community care groups, for example, assigns an elevated role to the informal sector in the network of care services (Cm. 849, 1989; Cm. 4100, 1998). Not only is the voluntary sector viewed as having a more prominent role to play in the provision of health and social care delivered within local communities, but it is also assigned an elevated role in the policy and planning process. The voluntary sector has, thus, formed the point of entry to the network, and relationships are viewed largely through this lens. This is not to suggest that the voluntary sector is more, or less, important than other sectors within the network or that other sectors could not equally be investigated in a similar fashion. Rather, it is offered as one window through which to examine the impact of health and social care restructuring within localised contexts.

The ‘anatomy’ of the voluntary sector is explored by building a description of that part of the voluntary sector involved in health and social care provision to the frail elderly and their carers, and its relationship to both the statutory sector and private care providers. The framework for understanding this process focuses on the ways in which actors located within the network transform - and are transformed by -other actors also situated within it. However, as access to, and the characteristics displayed by the various actors examined within the study varied significantly, it was necessary to innovate and specifically tailor the research design to maximise data collection opportunities from within each group. The design adopted an in-depth approach that increased the depth of data collected within the overall project. This approach is presented as being sensitive to the dynamic nature of change in agents involved in the provision of care to frail elderly populations. It is also one that places actors, and the linkages between actors, at the heart of the analysis, by undertaking interviews with key informants from within various agencies sited within the network. The book, therefore, seeks to uncover the inter-relationships and social processes occurring within the network based on understanding the experiences of actors operating within it.

It is acknowledged at the outset that the researcher’s position is one that is located outside the network. The research design, however, attempted to work with this, by adopting a methodological approach that facilitated an increased depth of study. By using in-depth interviews and diaries as methods of data collection, the study reflects the voices of those actors within the network. Secondly, the book aims to present this data in such a way as to maximise the voices of those actors participating in the study.

Legislatively, deinstitutionalised - or community-based - care focuses on four key care groups: the frail elderly, those experiencing mental ill-health, the physically and the mentally disabled (Cm. 849, 1989). Each of these ‘groups’ can vary enormously in their internal composition as well as the care needs of individuals located within them. Whilst there are differences, there are also many overlaps between the needs of individuals falling within particular care groups. To this extent, the composition of these groups is necessarily blurred, and attempts to draw boundaries around them are inherently flawed. In an aging population, for example, a key issue must be the point in life at which an individual becomes defined as ‘elderly’. Similarly dichotomies arise over the ‘boundaries’ between care groups when considering issues of aging and (i) chronic mental ill-health; (ii) physical disability; and (iii) sensory disability. Given that the ‘frail elderly’ are frequently presented as the care group consuming the highest proportion of community care funding, these are not idle questions. Nevertheless, these are the legislatively defined groups that researchers must seek to work with if they are to attempt to understand the impact of care restructuring. Thus, while acknowledging the flaws inherent within such definitions, the study attempted to work with the legislative context. The book has, thus, focused on care provision to just one of these community care groups -the frail elderly - in order to examine how policy enacted by central government is translated and transformed by actors operating at the meso- and micro-levels of the caring network.

While the definition of this group is open to debate, within the context of this book it is less immediate. The focus here is on care providers as actors within the network rather than service recipients. As such, the frail elderly are not, in themselves, central to the study. This is not intended to infer that service recipients are not actors within the dependency network. Rather, because of their experience as end-recipients of care provision, they are envisaged as the focus of a separate (though clearly inter-linked) piece of research.

The book has been constructed as two inter-related parts. The first locates the study within a contextual framework. As such, it weaves a path through a changing context of care which has at its root a policy framework that has shifted and developed over both time and space. This shifting context highlights the fluidity of research in this field. Care policies and their implementation are subject to constant revision and change arising from circumstances occurring at particular points in time. Given that the context is constantly changing, research in this area can never be ‘up to date’ - this is a situation that is both recognised and acknowledged. The book represents an investigation of relationships within the care network over a three-year period from 1996-1998. The effects of restructuring cannot be viewed adequately through a ‘snapshot’ approach, the interactions and effects of change in social care systems occur slowly. Such complex processes require time for exploration, with the interactions between people, policy and place demanding a longitudinal in-depth engagement with the social world of the informal provider within the chosen localities. Thus, rather than presenting the study as a ‘snapshot’ of care restructuring which is seen in isolation from past and future events, the analysis is viewed more as a ‘still’ from a moving film. In doing so, it allows us to recognise that not only is the situation subject to constant change, but also that while the focus may switch between arenas from time to time, these arenas are inter-linked by the medium of the ‘film’, and as such, are representative of the dynamic of the network.

The three chapters that follow lay the foundation and framework for the analysis of the substantive material contained in the remainder of the book. Each of these chapters contributes to the overall process of the study by illuminating a number of key themes through which it is possible to examine how the restructuring of health and social care is impacting on the voluntary sector - themes which are explored in the remaining chapters.

In chapter two, the book explores the development of different approaches to the examination of problems of health and illness. These serve as a means locating the study within its geographical context, and in particular, it considers the perspectives offered by medical geographers. Any discussion on the subject of care restructuring, however, also needs to incorporate an understanding of the key factors contributing to the development of newly emerging spaces of caring and an appreciation of the forces that have shaped their history. These issues are explored in chapter three. The final chapter in this section serves to locate the study within a conceptual framework, by exploring the utility of a networked approach as a means of understanding how care policy and practice is mediated within locally-defined contexts.

The second part of the book lays out the analysis of the substantive data. Each chapter explores how care restructuring is experienced by one set of actors within the dependency network and their inter-relationships within it - in particular with the voluntary sector. Chapter six is concerned with care restructuring as experienced by the voluntary sector itself. Chapters seven and eight consider the role of informal carers and the private sector experience of care restructuring respectively, and their influence on the shape of voluntary care provision. These three chapters are, thus, concerned with the experience of care restructuring within the informal sector. Chapter nine, however, ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of Figures, Tables and Maps
• Preface
• Acknowledgements
• List of Abbreviations
• 1 Introduction
• 2 Geographical Perspectives on Health
• 3 Policy and Place: An Historical Geography of Caring
• 4 Constructing the Conceptual Framework
• 5 Landscapes of Care: Issues of Design and Implementation
• 6 A Geography of Care Restructuring: The Voluntary Experience
• 7 Exploring Geographies of Informal Caring
• 8 The Private Sector and a Privatised Geography of Caring
• 9 Statutory Influences on the Geography of Caring
• 10 A Geography of Care
• 11 Conclusion
• 12 Epilogue
• Bibliography
• Index