Abstract
Julia Johnson, Sheena Rolph and Randall Smith (2010) Residential Care Transformed: Revisiting ‘The Last Refuge’. Basingstoke, Hampshire: Palgrave Macmillan, 285 pp. ISBN: 9780230202429, $85.00 (hbk). Reviewed by: Elana D. Buch University of California, USA
In ‘Residential Care Transformed,’ Julia Johnson, Sheena Rolph and Randall Smith follow a longer tradition of revisiting the sites studied in seminal scholarship, in this case, Peter Townsend’s 1962 book ‘The Last Refuge.’ Townsend’s classic study innovatively combined ethnographic and survey methods to examine residential care as it was provided to older adults in England and Wales at the dawn of the British welfare state. The book leveled devastating critiques at residential care, and especially at care provided in former Public Assistance Institutions (PAI’s – the formal term for Victorian-era workhouses). Townsend’s recommendations for improvement had a considerable impact on aging policy in Britain and led to a number of reforms in residential care. In many ways, ‘The Last Refuge’ is the book many social work researchers dream of writing – a book that is widely read among scholars, practitioners and policymakers for generations. It is a book that visibly contributed to public policy debates and broader social change. By revisiting the residential care homes studied by Townsend, ‘Residential Care Transformed’ helps trace the impacts that those debates and historical changes have had on elder care in the UK.
In designing the studies reported in ‘Residential Care Transformed,’ Johnson, Rolph and Smith employed a number of innovative methodological strategies to find out what had happened to the residential care homes Townsend had studied. In revisiting these homes, the authors hoped to ‘explore the historical processes of continuity and change at the level of individual homes’ (p. 12). In particular, they were interested in which kinds of homes survived, why some homes had closed as well as how surviving homes had survived the myriad shifts in elder care practice and policy in the decades since Townsend’s studies. Questions regarding the stability of residential care are critical if, as the authors note, ‘care homes are to offer people a real sense of “home” for their remaining years’ (p. 13). With these empirical aims in mind, the authors designed two complementary studies: a tracing study to find out what had happened to the 173 homes since they were visited by Townsend in 1958–1959 and a follow-up study comparing the physical environment, daily lives, residents, staff and quality of care in the homes that had survived, to examine changes between the late 1950s and mid 2000s.
To conduct the tracing study, the authors recruited nearly 100 locally-based older adults to serve as volunteer researchers across England and Wales, noting that these older adults – primarily retired professionals – had local knowledge and experience that helped them piece together what had happened to closed residential care homes. Each volunteer was assigned a home or homes to trace and fill out a ten-question form detailing both the history of the home and the investigatory methods used by the volunteer. The authors note that the volunteers gave each home ‘very comprehensive attention’ that made significant contributions to local history (p. 49). In reporting the findings of the tracing study, the authors follow Thompson by examining the comparative survival of four types of residential care institutions: ex-PAIs, local authority homes, voluntary homes and for-profit homes. Nearly a quarter of the homes Townsend surveyed had survived since the late 1950s, however shifts in aging policy had a considerable impact on what kinds of organizations have been able to continue providing residential care in the intervening decades. In particular, ex-PAI and local authority homes had the lowest survival rates, reflecting policies favoring the devolution and privatization of elder care. Moreover, the voluntary institutions in Townsend’s sample had been the most likely to continue providing residential care, suggesting that organizations driven by their mission may have greater longevity than those subject to either local markets or local politics.
The follow-up study drew a sample of the surviving residential homes to compare with those studied by Townsend. To provide a base of comparison between the 1958–1959 study and the current study, the authors replicated Townsend’s methods of collecting evidence, but made some modifications to accommodate both changes in policy and practice as well as methodological innovations. Data collection included: survey forms filled out by home administrators about residents and staff, interviews with a sample of residents; one week diaries filled out by a sample of staff and residents; a tour of each home (resulting in photographs and a cumulative home report).
While not particularly surprising, the findings from the follow-up study suggest that residential care fifty years ago served a very different population than residential care in the late 2000s, and thus, that residential care across eras is not entirely the same thing. For example, the current population of older adults in residential care was found to be significantly older, more frail but also somewhat less isolated from friends and family than their earlier counterparts. Thus, while Townsend argued that a substantial number of residents could live on their own in the community with greater support, the current study suggests a larger proportion of those in residential care are properly placed. This finding in particular, suggests the success of heath care practices and social policies that have helped elders remain healthy enough to live independently in the community for longer. These demographic changes, as well as changes in cultural understandings of aging are apparent in changes in residents’ daily routines. For example, in the past, residents were often expected to contribute some domestic work to the upkeep of the home, a practice which both engaged and potentially exploited older adults. The current practice of organized ‘activities’ such as bingo, exercise classes or group outings offers residents more choice in their activities, but also implicitly denies older adults the ability to productively contribute to their communities. In some ways then, this study shows that the meanings and practices signified by the term ‘residential care home’ have shifted substantially in the last fifty years from being a place to provide housing and surveillance for older adults with little social support to a place to protect and assist older adults with personal care.
One of the most interesting chapters in the book offers an excellent illustration of cultural and historical specificity of quality measurements. By using both Townsend’s original quality measure and the quality measure used by the British inspection agency to assess the quality of surviving residential care homes, the authors notably show that while there have been nearly across the board improvements in residential care according to Townsend’s standards. However, the authors note that while the physical environment and social amenities of residential homes have clearly improved, other differences such as improvements in staffing ratios likely reflect residents’ greater need for assistance and changes in the way homes are organized. Based on contemporary inspection reports, the authors note that there continues to be a substantial gap in quality between good and bad homes, which partially reflects economic disparities between their residents. They also found voluntary homes had a higher overall quality of care than for-profit homes.
‘Residential Care Transformed’ provides an excellent illustration of the impact that shifting social policies and demographic trends have had on the provision of residential care for older adults. In particular, the book proves that policies aimed at shifting responsibility for care from the state to the market and voluntary sector have been largely successful. While this study can only hint as to whether these changes are for the better, it suggests that for-profit homes are likely to be less stable providers of long-term care compared with voluntary homes. In comparing findings from the contemporary study to Townsend’s findings, the book provides an important comparison between the two time periods.
By focusing only on before- and after- comparisons, ‘Residential Care Transformed’ does little to help the reader understand the local historical processes of the intervening years. In the appendices, the authors choose to include two examples of the home reports filled out by volunteers for the tracing study, each of which are filled with historical detail and nuance. Greater analysis and incorporation of these reports, obviously a rich source of evidence, might have helped the authors to explicate the different local histories and circumstances that led to the survival of some homes and not others. Moreover, these reports might have illuminated more concrete information about how the closing of homes impacted residents, staff and communities, helping the authors to make more specific recommendations regarding the relationship between organizational stability and individual well-being.
Including more details from the volunteers’ reports, might also have enabled the authors to engage in deeper reflexive analysis regarding how the use of local volunteer researchers impacted their findings in addition to their somewhat lengthy discussion of the benefits participation may have had for these volunteers. ‘The Last Refuge’ has long been critiqued as reflecting Townsend’s personal belief that residential care was not in older adults’ best interests, rather than objective scientific data. Past revisiting studies have often contributed critical reflections on the ways in which the particular histories and social positions of the authors of classic texts may have influenced their arguments (for example, Annette Weiner’s (1976) reconsideration of Bronislaw Malinowski’s fieldwork in the Trobriand Islands, or W.A. Marianne Boelen’s (1992) revisiting of William Foote Whyte’s ‘Cornerville’ fieldsite in Boston). The use of volunteers, and a team of researchers to trace the histories and current conditions of residential homes might have offered a valuable opportunity to consider how differently configured research teams constrain or expand the ways evidence can be gathered and arguments made.
While authors occasionally make use of qualitative evidence gathered from specific institutions to illustrate a finding or describe an outlying case, for the most part the authors have tabulated qualitative data to provide summary findings about different types of homes. While this analysis is valuable, the consequence is that the reader is left with only the most general understanding of what life is like in the residential care homes that have survived from Townsend’s day. The authors note that Townsend’s vibrant description of life in residential homes contributed a great deal to its popularity, and thus to its influence on social policy. I cannot help but feel that ‘Residential Care Transformed’ falls short on this front, since ‘types’ leaves the reader without a concrete understanding of how residents or staff actually experience life and work in residential homes. Still, the book offers an important longitudinal perspective on the provision of residential care for older adults, and will be of interest to those interested in social provisions for the elderly, social welfare history or organizational change.