Abstract
This is the paperback edition of a book first published in hardback in 2010. Since then it was the winner of the British Academy’s inaugural Peter Townsend Policy Press book prize in 2011. Given that the book revisits both the methods of research and the outcomes of residential care homes, which were the combined subjects of Townsend’s earlier book (Townsend, 1962), this award is perhaps unsurprising. However, it is important not to downplay the excellence with which the authors have constructed their revisiting of the methods used by Townsend and their reappraisal of his findings. As a result, I can only echo the sentiments of Joanna Bornat, who wrote a preface for this paperback edition, that this is a ‘remarkable, innovative and exemplary interdisciplinary study’ (p. xiv).
Johnson et al. revisit Townsend’s study by tracing what had become of the homes in the original sample, and then follow up a proportion of these homes to ascertain how services are now delivered and received. In particular, they are interested in understanding the present through an immersion in past data. Their specific aims are policy-focused, methodological and theoretical in turn (p. 14). The main concern of this review is to reflect on the extent to which this edition is able to contribute effectively to debates on the future care of older people; as this is a policy journal such a focus is surely defensible. However, some consideration of the text from methodological and theoretical perspectives is a necessary precursor to this. In this context, it is as well to remember that Townsend was as much a social reformer as he was a researcher; indeed some reviews of his work highlight limitations in both his theoretical and methodological approaches (Jones and Fowles, 1984). However, Johnson et al. highlight some of the most innovative elements in Townsend’s research, notably the deployment of volunteer researchers. As well as providing depth to the analysis such an approach enhances the scope of the study. Townsend was also innovative in bringing the voices of those people who lived in the residential homes to the forefront of the research, an approach which is entirely in accordance with present-day thinking but which will have appeared unusual in the original context.
From the perspective of policy, Townsend focused on a critical question: is residential care for older people necessary and, if so, what form should it take? His exhaustive research meant that he was able to argue that it should be discontinued as a direct instrument of social policy, and that various forms of alternative housing and support should be developed in its stead. It is undeniable from even a cursory reading of the text that his research was critical in questioning much of the provision that dominated society at that time, with the malign influence of the ex-Public Assistance Institutions retaining such a significant impact; indeed, it was instrumental in securing a change of policy. In this respect, Johnson et al. have much to live up to. For this reviewer while they more than match Townsend’s work from a methodological and theoretical perspective, it is in the realm of policy that it feels significantly lighter; indeed, it is highly unlikely to have the same impact in this world than was achieved by Townsend. Indeed, this book does not appear to be motivated by the same core question.
That is not to say that the book lacks strength in the policy domain; however, the major changes in the delivery of residential care for older people have dramatically affected the possible impact of research, however critical and well-constructed. Two specific developments illustrate this well. The first is that the insistent demographic changes have vastly increased the numbers of older people who are placed into residential homes. Despite the policy preference for care to be provided in people’s own homes – to which Townsend’s original book was a significant contributor – there remain large numbers of people in residential care; indeed, it clearly still has a significant place in the pattern of service responses. Indeed, the main effect of demography has been to alter the levels of capability of those people in residential care, who are increasingly frail, both physically and psychologically. In addition, the vast majority of residential care is not now provided in the public sector. Following reforms to social security payments in the 1980s, the private sector grew rapidly – a change that was given statutory force by the National Health Service and Community Care Act 1990. As a result, the dictates of the market now dominate the care industry, with worrying effects on the quality of care and its security. From the original concerns about the insertion of the market into care (Means et al., 2002) there are now particular worries about the shape of the market that has developed and the problems that are being experienced in seeking to manage it (Scourfield, 2007, 2012). The latter points are critical in relation to society’s attempt to regulate and control the world of residential care for older people; the concentration of ownership into larger corporations has clearly changed the nature of an industry that was – in its early days – dominated by individually owned care homes. Although Johnson et al. do recognize the ‘corporatization’ of residential care (p. 207) they do not have the power to affect practice in ways that were open to Townsend 50 years ago.
Indeed, the pressure to diversify into alternatives to residential care in the private sector is affected by the fact that, as Johnson et al. observe, many companies prefer to invest in the less risky area of care homes rather than more personalized services provided outside of the institutional context(p. 215). As a consequence, it can be argued that the continued existence of a large residential care sector is an obstacle to ambitious plans to personalize care. In other respects, however, Johnson et al. observe striking continuities with the past. The most positive homes appear likely to be located in the voluntary sector, while the pay and conditions of staff remain poor and hence problematic. The image of residential care is also still negative, affecting the way in which the entire sector is perceived in the early years of the 21st century; despite this, there were still examples of extremely good practice. Despite the cost of the service, there remains a sense that it is little valued; there is also no sense that residential care for older people will be returned to largely public ownership, due to the prohibitive cost of taking such action.
Perhaps the clearest lesson is that policy makers have taken little notice of research that highlights the reality of people’s lives in residential care (pp. 215–216). As a result, the sector has been less well developed than is clearly indicated. Given that there will continue to be a need for some form of residential care for the most frail older people this neglect is shameful, as the book amply demonstrates.