What happens when you turn care into a commodity, asks Alex McClimens.

Welcome to 2016. I'm going to start the New Year by throwing numbers around and asking, What happens when you turn care into a commodity? Here goes… in his pop science book Outliers (Gladwell, 2008) the author implies that success is founded on many hours of assiduous practice. He cites The Beatles – for younger readers, they were a popular beat combo of the 1960s – and suggests that their apprenticeship, playing clubs in Hamburg and Liverpool, amounted to 10,000 hours. 

This figure stuck as a magic number until recently when a meta-analysis by McNamara et al (2014) into 'deliberate-practice' across a range of domains found that in education, for example, the variance in performance that could be attributed to practice (after other variables were excluded) was a meagre 4%. McNamara also looked at professions. Here it was found the figure was even lower at just 1%. So what can we realistically expect students enlisted on professional health and social care courses to gain from all the hours of education and practice they endure? For would-be professionals in training the total 'practice' time equates to about 3,000 hours. And that won't get you into the Beatles! 

But where to practice? Students need quality placements where they can learn their craft. These need to be well regulated and signed up to the governing NHS principles. And here comes trouble. Ever since the NHS and Community Care Act (1990) expanded the geography of placement locations regulation has become much harder to manage. Add to this the subsequent changes to healthcare delivery, the proliferation of agencies and stakeholders who can now, thanks to the principle of 'Any Qualified Provider', operate in the milieu of health and social care and the terrain in which student nurses learn their craft is almost unrecognisable to that experienced by those who attempt to educate them. 

In a generation we have gone from utilising the decaying Victorian 'loony bin' funded by central government to providing experiential learning in a new mixed economy of care. In learning disability services at least this is characterised by supported living models. These are largely financed by individual budgets with an overall policy emphasis on market-driven approaches to care provision operating within a light-touch regulatory framework. Well, it worked for the banking sector, didn't it? The downside to this is that you can get greedy, uncaring, shareholder-led companies owned by venture capitalists that put profits before people. 

Local authorities could provide these services themselves but with the added pressure of fiscal austerity could they afford to? And most private companies are limited by guarantee - councils aren't. Or the local authority could set up its own limited company and take care provision back that way. Then they would have to comply with all the monitoring. 

Andrea Sutcliffe, the chief inspector of adult social care at the Care Quality Commission (CQC), spoke last August of the consequences of low investment in social care (Boffey, 2015). The CQC was then handling more than 150 allegations of abuse every day. The proposed rise in the minimum wage might even contribute to this as private companies see their share dividend adversely affected. They can sell up or they can cut costs. 

In a speech last May at the University of Edinburgh Corporate Finance Conference, Andrew Haldane, chief economist at the Bank of England, made some observations on just this topic. He noted that the corporate business model was likely to have what he referred to as 'micro-economic frictions'. This is banker-speak for trouble waiting to happen. Haldane warned that low investment in staff and resources could lead to potentially higher risk for users and customers. If it was only money it would matter less. 

There are alternatives. The Rudolf Steiner model as practised in Camphill communities offers a cooperative environment based on volunteering. But even this philosophy has succumbed to business practice as proposed changes advocate moving from volunteers to employees. Employees means employers. Employers means regulation. Regulation means the social experiment failed and the bean counters are now running the asylum. And that's what happens when  you turn care into a commodity. Yeah, yeah, yeah, yeah (G6).


Boffey D ‘Social care chief savages failing system for elderly’. The Guardian, 8 August 2015. Available at: www.theguardian.com/society/2015/aug/08/social-care-chief-inspector-system-failing-elderly

Gladwell M (2008) Outliers: The Story of Success. New York: Little, Brown and Company.

Haldane A (2015) Who owns a company? - speech by Andrew Haldane. Available at: www.bankofengland.co.uk/publications/Pages/speeches/2015/833.aspx

McNamara BN, Hambrick DZ & Oswald FL (2014) Deliberate Practice and Performance in Music, Games, Sports, Education and Professions: A Meta-Analysis. Psychological Science, 25(8) 1608-1618.

About the author

Alex McClimens began working with people with learning disabilities in Edinburgh in the 1980s. He then when to Sheffield where he spent time in community services before moving into teaching. He currently works in the Centre for Health & Social Care Research at Sheffield Hallam University, where he divides his week between scholarly activity and contributing to student placement experience.