The grip of personalization in adult social care: Between managerial domination and fantasy

Personalization as empty signifier

Personalization-transformation as a policy promises liberation and, as such, is symbolically useful. Beresford (2009: 3) argues that it marries two competing sets of concerns: ‘the emergence of a democratising collective impulse in public policy; and pressures to restore market dominance following its fettering by the post-war welfare settlement’. Lymbery (2010: 5) points also to the cultural imperative in which ‘it is presented as the inevitable consequence of the changed expectations of people who use services’. Personalization has come to stand for a number of competing and contradictory demands: modernization through choice; the management of potentially escalating demands within a context of fiscal retrenchment and demographic change; the rejection of standardized services and the call for greater citizen involvement and autonomy; and the bolstering of private markets for social care services and products. It has, then, as Needham (2011b) notes, something of the character of an ‘empty signifier’ (Laclau and Mouffe, 1985).

What I now want to examine is the way in which the discourse of personalization, or perhaps more accurately, personalization-transformation, persisted in Council A even through an utterly unsympathetic fiscal context in which it became quite apparent that its autonomizing potential simply could not be delivered.

The original proposal

In 2006, Council A commissioned a study to examine the financial sustainability of its adult social and community care services. The conclusion was that a major reconsideration was required to bring the Council into line with government’s and citizens’ expectations of greater independence and dignity, and to meet the financial challenge associated with an ageing population. In May 2009, the Council put forward a Business Case for what came to be described as a Transformation Programme, bringing it into line with prevailing central government policy. The Business Case put forward three scenarios:

The option agreed upon by the Council was a ‘Transformed Service Delivery Model’, broadly in line with scenario 3. This would place the emphasis on personalization which, it was asserted, would ‘drive out the inefficiency that is inbuilt within some of our current models of care’, in particular the inefficiencies associated with direct service provision (Council A Revised Full Business Case for the Transformation Programme, 2009). In line with the prevention theme, it proposed to invest in advice and information to enable citizens to make more informed choices. This would also facilitate the development of a market for care services. It proposed also to invest in re-ablement services for people returning home from hospital. It also proposed a more proactive approach to assistive technology in the home. In short, personalization, the promotion of prevention and the widening of choice in the market of care services were the key elements of the Council’s ‘transformative’ approach to adult social care. The long-term aim was to prevent more expensive residential and acute hospital care. This is not to say that self-actualization and autonomy were not important for the Council (Council officials often spoke zealously of the liberating potential of personalization), but its potential to realize cost savings was identified very early on, and, if anything, this motivation for personalization strengthened as the squeeze on Council resources tightened following the government Spending Review in October 2010. What is important to note is that at the early stage the Council was not proposing to restrict eligibility criteria for Council supported or funded social care. There was, therefore, nothing especially controversial in the proposals that would have necessitated public consultation or provoked significant contestation.

Personalization-transformation phase 2

By the following year the fiscal landscape of the Transformation Programme had utterly altered. Early warnings of the coalition government’s autumn Spending Review led the Council to set out drastic budget reductions that would avert the need to raise Council taxes. Spending on adult social care amounted to over one third of total Council spending. It was estimated that Council expenditure needed to be reduced by approximately 30% over a four-year period. Given the ring-fenced nature of much of the Council’s other spending, and given that the tight timescale for the implementation of budget cuts precluded detailed examination of each of the Council’s budget items, it was determined that the Council’s social and community care department achieve a saving of approximately 10% of adult social care spending in 2011/12 rising to some 20% by 2014/15. The key point to note here is that that decision appears to have been a largely administrative one, not a political one, a conclusion also drawn by the High Court in its conclusion of the Judicial Review. Additional money was made available by central government to minimize the impact of spending reductions in adult social care. It was, however, argued that this still left a shortfall of £10 million on the required savings and would do nothing to place the adult social care department on a sounder financial footing in future years.

I do not in any way seek to deny the invidious position of the adult social care department in Council A, but what is interesting is the way in which it then sought to manage this symbolically and, in particular, how personalization was deployed to signify hope and to attenuate the trauma of austerity. For there was one significant detail that came between the original proposal and personalization-transformation phase 2: eligibility for Council arranged and funded social care would be restricted to those with critical care needs only, something which only two other councils in the country had sought, and failed, to do, and something which even government guidance had counselled against (DoH, 2010b). In other words, a conservatively estimated 4,000 people would be denied even the possibility of obtaining a personal budget to fund their social care. Moreover, the Council was not in a position to say with any precision what sums of money would be available even to those who would be eligible for a personal budget. So the very pretext of transformation – personalization – would be relevant only for a very small proportion of social care users and, moreover, as Needham (2011b) points out, the autonomizing potential for those with critical needs is, in any case, questionable.

The Council’s consultation document, entitled ‘A vision for adult social care’ set out two stark choices in the familiar format of innovation and ‘no going back’: 1) business as usual (but worse); or 2) transformation through personalization. It stated that its clear preference was for the second, transformation option, which would include the key elements of the transformation package. What is particularly notable here is that the most controversial element of the new package, and the very element that would instantly signify this as an austerity rather than a transformation package – the restriction of eligibility criteria to critical needs only – was mentioned merely as a qualifying statement on the implementation of individual budgets.

Again, I do not deny the difficulties facing the Council. What is of interest is the way in which the Council sought to pass the ‘new offer’ off as part of a transformation programme, strongly connoted with personalization as liberation and empowerment and signifying dignity and self-actualization for social care users. In fact, the consultation document starts with the following statement:

We want to continue to develop new approaches to providing adult social care services including giving people and communities more power and control. (Consultation document, December 2010, p. 13)

The fact though is that the transition to a universal resource allocation system potentially means a further tightening of individual budgets, and the restriction of eligibility criteria denies many the very possibility of even obtaining a personal budget in the first place. In the meantime, valued collective services had already been dismantled.

The consultation period, which was perhaps accurately described by one senior Council official as ‘an awareness raising and engagement plan’, lasted three months and culminated in the almost wholesale adoption of the proposals by the Council’s Cabinet. Concurrent with the public consultation process, however, three individual disabled residents of Council A submitted applications to the High Court for Judicial Review on the grounds that the Council had not carried out its statutory duty under Section 49a of the Disability Discrimination Act of 1995, and on the grounds that the consultation process was flawed. Their case was eventually upheld. The High Court’s judgment and the Council’s responses to it reveal much about Council A’s modus operandi, and, in particular, the fantasmatic frame (a concept to which I will return) in which it appeared to be operating.

Democratic deficit and the Judicial Review

The Judicial Review turns on the question of whether the Council complied fully with its duty to carry out an assessment of the equalities implications of its proposals. What the detail surfaced by the Judicial Review reveals is: a) the thinking of the Council’s lead officers in adult social care at the time; and b) the Council’s approach to democracy. While the judge appears to have some sympathy for the officers, who were, it must be said, working to an impossible timetable for consultation, it is highly critical of the Council’s political representatives.

The head of adult social care made written statements to the High Court. In these something of the officers’ logic was revealed. He explained that its entire transformation programme started from a consideration of how best to meet the needs of disabled people in Council A over the longer term and especially considering the looming (in his words) ‘international crisis of the ageing population’. In his view, the current model of direct provision could not be maintained. The Council prided itself on the implementation of individual budgets ahead of the mandated timetable, deeming what went before to be ‘centralised and bureaucratic’. He reasoned thus:

[we] believe it is in their interests to get away from a culture of unsustainable dependency and as soon as we can. … even if (which it is not) the money were available to sustain the former and develop the latter at the same time, that is not an approach which works. Furthermore, it is a value-judgment that authority-provided or funded services are necessarily ‘better’ than helping people to help themselves and/or to obtain help from family, friends and the wider community.

The question was whether officers were right in their assertion that moving to critical need only could not be avoided. The judgment was that political representatives had failed to probe on this very question and to seek the information on equalities that might have led them to an appropriate answer. This ‘failure to ask the right questions’ ultimately led the judge to quash the Council’s budget and plan to restrict eligibility criteria, asserting that the Council could have sought to continue to fund substantial needs by cutting budgets elsewhere. The High Court was equally critical of the Council’s wider public consultation exercise.

One interpretation, then, is that this was an officer-led programme, which was in thrall to the transformation package and its underpinning logic of self-reliance, markets, community support and a general shift of resources to prevention and re-ablement. At no point did this underpinning logic ever appear to be the subject of political challenge by elected members of the Council, even in the face of the most draconian budget reductions in the Council’s history. Even if political representatives of the Council were caught by a sense of inevitability about the budget cuts, it still had a duty to enquire as to their impact on its citizens. Its failure to do so led to the High Court to rule against its proposal to restrict eligibility criteria.

Deficit reduction marches inexorably on, but still ‘we’re making it personal’

Some six months after the High Court ruling, the Council went back to public consultation. The formal consultation document states that eligibility criteria, following the ruling, will not now be restricted, although lawyers in the field are uncertain about what that means in practice. The draconian budget savings required of the Council, however, not only remained, but, in the light of a further 6% budget cut imposed on the Council generally, will require the non ring-fenced Adults and Communities budget to shrink yet further. Still, the Council insists on its Transformation Programme, of which rhetorically personalization remains the driving concern. To quote the Council’s second consultation document:

This approach to adult social care is called personalisation and is in line with the Government’s commitment to transforming adult social care. Self-directed support means you can choose how you want to manage your care services, giving you more control over the social care support you can get. In this way, we are providing a much more personal approach to adult social care services.

Again, the Council’s Adults and Communities strap-line remains: ‘We’re Making it Personal’.

So, to summarize. We have a local care system facing the deepest cuts in living memory, where considerable doubts remain about whether eligibility for Council support may still, in fact, be restricted by means other than moving to critical need only. Yet, the Council’s programme continues to be signified as one of ‘transformation’, ‘self-direction’, ‘choice’ and ‘personalisation’. How, then, can we account for the ideological efficiency of personalization-transformation?

There are some excellent ideology critiques of personalization, some of which are discussed above. Needham (2011b), in particular, offers a thorough account of the trajectory and purchase of personalization. She expresses pessimism at the likelihood of personalization taking ‘progressive forms’ (Needham, 2011b: 170). What we have seen in the case of Council A, and in the specific context of social care, is personalization-transformation’s sublime ideological efficiency. It provides ideological cover for the most draconian of austerity measures. Its ideology efficiency is arguably even further advanced since the publication of Needham’s book, to the point where there appears to be a total disconnection between the discourse of personalization-transformation and the policies that are implemented in its name. This requires critical theorization.

Two bodies of critical scholarship are of interest. Both eschew any presumption that ideological formations can be dislodged purely by reasoned and objective appreciation of their applicability to a given pragmatic context. In the light of the case of Council A, this would seem to be a wholly appropriate theoretical starting point. First, since we are dealing with the passage of an ideological formation through a process of public consultation, I draw on Luc Boltanski’s recent work on the sociology of critique. Boltanski’s thinking on the role of institutional actors is an important starting point for understanding the way in which institutions can subvert and suppress political contestation. It offers one way of understanding the democratic deficit in the case of Council A. More specifically, his concept of managerial domination enables us to account for the efficiency of the articulation of personalization with transformation. Arguably, though, the case of Council A demonstrates that the grip of personalization goes beyond institutional efforts to suppress the political. It is not just that in managerial domination institutional actors succeed in evading the ‘deconstructionist critique’ of ordinary people (Boltanski, 2011: 135), it is also that personalization appears to exercise a certain hold even over those who disavow its current trajectory. This requires a different kind of critique: one that is about ‘encircling’ (Stavrakakis, 2007) that which escapes symbolization. Here we draw on Lacan-inspired psychoanalytic understandings of ideologies and their power to affect.

Judicial Review: ‘A micro response to a macro problem’

In Boltanski’s model of managerial domination, we also have the means of interpreting the special role of crisis in cementing ideologies. In particular, it provides a framework for understanding why, paradoxically, crises, far from unsettling ideological edifices, often have the effect of cementing them. This certainly seemed to be the case with Council A. The second wave of consultations seemed to be an exercise in retroactively constructing the deeper enquiry that ought to have taken place in the first instance. Most of the questions consisted of asking people to confirm that they had understood the implications of the original transformation proposals. From the perspective of managerial domination, crises ‘provide the opportunity for a regime of domination through change to reassert its control’ (Boltanski, 2011: 135). What manifests is no longer a constructed reality, but ‘reality as such’, indifferent even to the will of experts (Boltanski, 2011: 135). Institutional leaders invoke necessity ‘to give their intentions firm backing’ (Boltanski, 2011: 135), thereby evading ‘deconstructionist critique’ (Boltanski, 2011: 135). Moreover, these leaders, situated within broader networks of expertise (economics and management) are afforded great scope (and are even required) to eschew strict interpretation of the rules, while still observing something of the spirit of the rules (Boltanski, 2011: 145).

These observations on the contemporary mode of managerial domination are, again, illuminating in the case of the transformation of adult social care, both generally and in the specific case of Council A. As we have already noted, national policy encourages the simultaneous extension of personalization to all user groups and the development of universal preventative services, and this is precisely what Council A sought, and still seeks, to achieve. In a context of resource munificence, there is no contradiction between these two objectives. In a context of extreme fiscal contraction, however, the development of universal services can only come at the expense of meeting care needs. As Clements has noted, personalization tends to convert ‘the right to social care into a right to a fixed non-discretionary (monetary) entitlement’ (2008: 416) through self assessment or some kind of resource allocation system. This is the mechanism that limits local authority financial obligations, but where it comes to replace a community care assessment, it is outside of community care law (Clements, 2008, 2011). Local authorities are, therefore, tacitly licensed to shift resources from meeting need to offering universal services of prevention. Given that national policy relies on legal ambiguity, it is no wonder that local policy actors are ambivalent about the rules. A Judicial Review has the effect of pulling policy actors momentarily back to the rules and diverting them from pragmatic politics. The responses of senior officers in the case of Council A are telling in this regard.

In their summary of the Council’s case, its barristers characterized the Judicial Review as ‘a micro challenge to a macro decision’ and argued that such concerns were matters of ‘petty bureaucracy at quite a low level’. For his part the director of adult social services reasoned that the Council had a ‘generalised awareness’ of the duty that the Council had to carry out an equalities and impact needs assessment, and that that duty had always been implicit in its proposals to concentrate investment on preventative services even if it had not been strictly carried out in the precise manner required by the rules. Its intention was always to ‘invert the triangle of care spending’ (ADASS/LGA, 2002) by giving ‘people the opportunity to have as much independence, choice and control as possible by being in charge of their own care’, and the Judicial Review appears to have made no material difference to the underpinning logic of personalization-transformation. The demographic and cultural imperatives for transformation are said to persist, and while institutional actors may not be observing the letter of the law they are certainly in compliance with the spirit of national policy intentions. Meanwhile, there is no additional money available to give personalization significant liberating potential. If anything, the financial position has hardened. Still, the Council insists ‘We’re making it personal.’

Now, I must emphasize the plight of institutional actors. They are caught in an austerity trap, seeking to make the best of the impossible situation they have been handed and, moreover, are more or less required by national policy to bend the rules. Personalization is part of the coping strategy. It signifies hope. However, what I argue is that to thoroughly critique the persistence of the personalization-transformation discourse, and to fully comprehend the political work it accomplishes, requires attention to be shifted from the capacity of conscious institutional actors to manipulate the symbolic field to the broader ‘psychic economy’ (Glynos and Stavrakakis, 2004) of which personalization-transformation is a part. The response of a participant at one of Council A’s consultation events is instructive here. On the question of the meaning of personalization in Council A’s plans, he stated: ‘This isn’t personalisation. This is personalisation plus.’ The ‘plus’ referring here to the cost saving element of personalization. One interpretation of this statement is that while the current implementation of personalization in Council A is disavowed, the respondent is unwilling to give up on it as an ideal, holding out for more conducive conditions. But, what is personalization as an object that makes it hard to abandon even though its ideal conditions are never likely to materialize? To paraphrase Žižek (2008c) what is in personalization more than personalization?

The basic conceptual architecture

First, a theoretical distinction is drawn in Lacanian theory between linguistic/symbolic constructions and symbolic identification, on the one hand, and fantasies/symptoms and their ‘enjoyment’, on the other. Lack is fundamental to both symbolic identity and to enjoyment, but the latter is characterized precisely by its positive contents (Stavrakakis, 2005). Lack points to the castration of the subject: what the subject leaves behind when it enters the cultural world of language, the symbolic world. The castrated (or split) subject feels this lacking identity, but can never re-capture it fully. What partially fills this lack is the subject’s identification with some feature of the symbolic order – ‘the Other’ (Žižek, 2008b). This happens on two levels: the imaginary and the symbolic. On the imaginary level, the subject identifies with an image in which she appears likeable to herself (Žižek, 2008b) whereas in symbolic identification, the subject identifies with the gaze from which she appears likeable to herself – ‘the very place from where we are being observed’ (Žižek, 2008b: 116, emphasis in original). She assumes a symbolic mandate. However, it is not just the subject who lacks, but the symbolic order, the Other, also lacks. It is not a closed totality and the subject is never quite sure what she is within the symbolic order. She is disturbed by the lacking Other’s unclear demand of her – as Žižek puts it: ‘to the unbearable enigma of the desire of the Other, of the lack in the Other’ (2008b: 132). Fantasy is then the answer to this ‘unbearable enigma of the desire of the Other’. It ‘answers the question of what I am to the [O]ther’ (Dean, 2007: 20). It gives the subject a script that regulates her own desire; what she lacks, what she needs to be complete and why ultimately she can’t get it. Fantasy is the organization of desire, not the fulfilment of desire. It explains why enjoyment is missing (Dean, 2007) and, thereby, maintains the subject as a subject of desire.

So, the grip or force of an ideology, then, depends not just on its success as a signifying chain, but also on the extent to which it simultaneously promises the recovery of lost enjoyment and an explanation of why that can never be fully recovered; of why the subject still lacks. What is needed to explain and ultimately ‘traverse’ the ‘fantasmatic grip’ (Glynos and Howarth, 2007) of an ideological edifice is not to interpret it deconstructively, but rather to seek to identify the ‘kernel of enjoyment’ – enjoyment beyond meaning one might say – that effectively holds it in place; a psychoanalytic operation more than a deconstructive one.

At the level of the collective, what is of interest is the co-construction of and libidinal investment in social projects – for example the nation (Stavrakakis, 2007) or patient choice (Fotaki, 2010). Social projects which act as the last support of the status quo and offer a ‘sense of guarantee’ (Chang and Glynos, 2011) when confronted with the radical contingency of social relations as, for example, the onset of austerity.

The subject under the gaze of Beveridge?

One place to start in ‘encircling’ this enjoyment of personalization is to ask who are the subjects and what is the symbolic universe within which this psychic economy circulates?

Personalization as social imaginary may be operable in a variety of symbolic frames. Fotaki, for example, has posited that choice in health and social care is a way of avoiding the trauma of the ‘finitude of our physical bodies’ (2010: 714). This is undoubtedly also valid for personalization, a near neighbour concept. Needham identifies a range of ‘policy entrepreneurs’ in the field of social care who have been largely responsible for ‘crafting and disseminating the personalisation narrative’ (Needham, 2011b: 71) as a means of increasing ‘the power and dignity of people using social care’ (Duffy, 2010: 1). Among these are disability rights campaigners, principally organized through the government-backed social innovation network In Control (Boxall et al., 2009; Needham, 2011b), leading academics and the left-leaning think tank, Demos (Ferguson, 2007). What is also striking, however, is the way in which the imaginary of personalization has become entangled in the symbolic frame of welfare state development.

Personalization has been posited as the principle for a fundamental redesign of the welfare state, an idea most starkly put in a think piece by Glasby, Duffy and Needham (2011), titled: ‘A Beveridge Report for the 21st Century? The Implications of Self-directed Support for Future Welfare Reform’. The reference to Beveridge – emblem of the founding moment of the 20th century welfare state and decisive break with the Victorian Poor Law – is, I would argue, not merely incidental. It promises not just the continuation of the welfare state – itself a highly contestable proposition before and especially since the onset of austerity – but also its perfection. Not a return to Poor Law values, but, with personalization, the promise of the perfection of the Beveridge welfare state with autonomy, justice and full citizenship for all. This, I think, takes us towards the ‘kernel of enjoyment’ in personalization. At the level of meaning, we could say, with others (e.g. Boxall et al., 2009; Ferguson, 2007; Needham, 2011b) that personalization is a way of reconciling competing policy imperatives in an empty signifier around which there is ongoing hegemonic struggle for the particular content which will come to fill it. At the level of enjoyment, on the other hand, personalization is the fantasy that explains why we cannot achieve a perfect welfare state. It is Beveridge to whom we appear likeable to ourselves as entrepreneurs and promoters of personalization, and it takes us closer to understanding why it is possible for an austerity management package to be signified as ‘making it personal’ without significant rebellion. For what is also striking, is the way in which the rhetoric of a ‘for and against frontier’ has been deployed by its advocates (Glasby, 2011; Henwood, 2008; Needham, 2011b). Even those of us who are critical of, and disavow, the current policy trajectory, not wanting to be seen to be on the wrong side of this divide, hold fast to the ideal of universal personalization (Ferguson, 2007; Needham, 2011b). What we see in Council A may not be personalization, but it does at least hold it on the horizon of possibility.

Personalization as ‘perfected Beveridge’, then, may explain why personalization in A, for example, is ‘not personalisation period’ but ‘personalisation plus’. It brings us closer to understanding this ‘irrational exuberance’ for personalization (Clements, 2008). But, we must also address how personalization operates as a psychic economy, and in particular why its failure is a key element of its ideological success.

The necessary and inevitable failure of personalization

Policy fantasies, then, unfold within particular psychic economies which are not about achieving our desire but, on the contrary, are about organizing and maintaining that desire. Rather than face our lack, they provide us with a script that explains why we lack. In this case, I argue that personalization is the imaginary that is valorized from the vantage of a perfected Beveridge welfare state. At the symbolic level, personalization-transformation is certainly an empty signifier, but more than that, it is the fantasy that explains why the absent fullness of the perfected Beveridge cannot be attained. It cannot be attained because universal personalization cannot be attained. There is, in fact, considerable empirical evidence that personalization does not work for older people, for example (Lymbery, 2010), the largest group of social care recipients. Pilot evidence suggests, at best, mixed evidence of the benefits of personalization for older people (Glendinning et al., 2008). Uptake among them is low (Lymbery, 2010). There is far more that could be said here about older people as a ‘symptom’ of personalization; the point of ‘inherent exception’ (Žižek, 2008c: 211) in the universalization of personalization across all user groups, but that is beyond the scope of this paper. Suffice to say that either this exception is not registered – there is for example no mention of this in the Glasby et al. piece discussed above – or, if it is registered (see for example ADASS, 2012), the solution is not to abandon the idea, but to seek to render it workable. What is claimed is that older people require more choice and more control and more coaching and support in that objective (ADASS, 2012). But, the expenditure involved in delivering the necessary level of support is, of course, an impossibility under the current parsimonious welfare settlement (or indeed, arguably, under any likely future welfare settlement). Now, of course, to work as fantasy, it is only necessary that personalization promise the recovery of lost fullness, or lack. In order for desire to be sustained, the subject must have some kind of ‘partial enjoyment’ (Stavrakakis, 2007) of the object, and we have already seen how uplifting good news stories attest to personalization’s universal potential. But that promise of fulfilment must also be coupled with ‘dissatisfaction and frustration’ (Stavrakakis, 2007). Personalization sustains our desire for a perfected Beveridge, even in the face of rampant austerity.