Agency and the Limits of Responsibility

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This entry is adapted from the peer-reviewed paper 10.3390/socsci12040248

Residents responded differentially to technology, based on their levels of capability, motivation, reluctance and resistance. Small technological innovations could have disproportionately positive impacts in improving wellbeing, the research demonstrates the complex nature of agency and limits of responsibility.

technology-enabled care co-management ageing supported housing

1. Introduction

The UK government’s introduction of extensive welfare reforms (from at least 2012) has seen social housing providers increasingly engaged in ‘housing plus’ activities, such as income maximisation and other interventions to enhance wellbeing, addressing the social welfare needs of tenants (Blank et al. 2019). A prime objective of these reforms was to extend personal choice and autonomy, encouraging individuals to be accountable for their own behaviours and welfare, with social service providers being co-opted to facilitate behaviour change. There is also a noted tension in the negotiation of planning for ageing between personal responsibility and public intervention (McCall 2022). With respect to responsibilisation in health and social care contexts, technology plays a key role in helping individuals to be self-managers of their own care, thereby (in theory) easing demands on health and social care infrastructure (NHS 2020). There is a sizeable body of work focusing specifically on the impact of ‘digital health technologies’ to improve the support, information and health outcomes of clinically vulnerable populations, and to empower older patients to self-manage their healthcare, improving self-efficacy and ‘self-control’ (Gaikwad and Warren 2009; Chiarini et al. 2013; García-Lizana and Sarría-Santamera 2007). In responding to the needs of older and more vulnerable tenants, supported housing providers have incorporated a range of assistive technologies, including ‘lowlevel’ aids to help with day-to-day living as well as higher-level technology such as remote care services via ‘telecare’ and various forms of mobile digital technology, in the provision of housing services (Varey et al. 2021).

2. Responsibilisation, Technology and Co-Management of Care in Supported Housing

The concept of responsibilisation is often situated within a wider agenda of neoliberalism, which as an economic project that calls for the deregulation of markets and the privatisation of services provided by the public sector, such as housing and social welfare. As a political agenda, neoliberalism advocates limiting the role of government in welfare whilst extending its intervention in policing and supporting markets. Civil society under neoliberalism comprises ‘consumer’ citizens, a collection of individuals who compete to pursue their own self-interest (Adams et al. 2019). Individualism is therefore a key tenet of neoliberalist ideology, with the consumer citizen being autonomous, individualised, self-responsible, self-acting, and self-directing (Bondi 2005; Cradock 2007). At a systemic level, the ideal neoliberal individual takes responsibility for their own behaviours (Brown and Baker 2012), and within a health and social care context, does not rely on the state to provide health care and social welfare (O’Malley 2009). Responsibility is imparted on individuals through personal choice and autonomy—it is the means by which citizens participate in their own self-discipline (Trnka and Trundle 2014; White 2002). Service retrenchment is therefore justified as citizens assume greater responsibility for their own welfare.

In the UK context of a shrinking welfare state and a national health system increasingly incapable of meeting the social care needs of an ageing population, some social landlords have widened their service, offering to include a range of social support, focusing on more holistic interventions for social tenants (Power et al. 2014). Housing support, for older renters especially, lies at the interface between health and social care (Blank et al. 2019). In addition to delivering support to older people in mainstream social housing, many social landlords are engaged in the provision of ‘sheltered’ or ‘extra care housing’ for older people (Housing LIN 2015). The scale of supported housing has grown markedly over the past two decades, as national government, local authorities and social housing providers have attempted to respond to increasing demand from an expanding older population (Darton 2022). In the process of growth, the range of models has also become substantially more diverse. However, there are several common features which can be identified, which aim to address age-related issues, including self-contained properties within buildings which are purpose-built or adapted for age/disability-friendly design; those with communal facilities which enable group activities; those with a back-up alarm system and other assistive technologies; those with a restaurant or dining room; and those with some level of staffing on-site or covering multiple sites (Housing LIN 2016). All of these elements are intended to enable people to remain living in this relatively independent setting as they age, thereby avoiding the need to move into residential care. The growth of supported housing is therefore driven by the individual desire to retain independence in later life, but also by budgetary pressures on local authorities, who are responsible for the care costs of low-income households (Darton 2022).

Whilst the above discussion is useful in illustrating the challenges placed on institutions and organisations to promote responsibilisation, analyses at a systemic level often neglect focusing on implications for individuals and communities. Critics of neoliberalism argue that the concept of responsibility ignores the role of social relationships, with individuals being viewed as autonomous rather than socially situated actors (Freeman and Napier 2009). At a conceptual level, a major criticism of ‘responsibilisation’ within the literature on advanced liberalism and governmentality (in which the concept originates) is the over-rationalisation of power and its exercise, which downplays the complex nature of agency and social relationships (Flint 2002). For example, few studies concerning the role of technology in health responsibilisation have acknowledged how older adults use technologies in collaboration with other people, such as family carers (Lindberg et al. 2013; Magnusson et al. 2004; Reeder et al. 2013) and health care professionals (Oudshoorn 2008; Segrelles-Calvo et al. 2016). These studies demonstrate the importance of social context (created by relationships with other people) in relation to health (Wiltshire et al. 2018; Frohlich et al. 2001; Robertson et al. 2022) and illustrate how a co-managed approach to technology-enabled care can be effective. Such studies emphasise the role of collaboration and partnership between individuals, family members, professional carers and others in their support network.

Co-managed approaches call for greater recognition of the mutually constituting impacts that technologies and care services have on each other (including how care is defined within policy discourses). In terms of delivery, co-managed approaches involve designing and implementing services which emphasise a shared understanding of technology-enabled, or perhaps more accurately, technology-mediated care. The research undertaken for this article therefore focusses on such co-managed approaches by paying attention to the ‘hidden work’ of housing support staff, as well as of family and other residents, to support technology-enabled care in residential settings, thereby demonstrating the limited extent to which older and more vulnerable tech users can be expected to be self-managers of care.

References

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McCall, Vikki. 2022. Inclusive Living: Ageing, adaptations and future-proofing homes. Buildings and Cities 3: 250–64.
NHS. 2020. Empower the Person. Available online: https://digital.nhs.uk/about-nhs-digital/our-work/transforming-health-and-care-through-technology/empower-the-person-formerly-domain-a (accessed on 29 November 2022).
Gaikwad, Rekha, and Jim Warren. 2009. The role of home-based information and communications technology interventions in chronic disease management: A systematic literature review. Health Informatics Journal 15: 122–46.
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Regina C. Serpa

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Grant Gibson

Julia Lawrence

Vikki McCall

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Update Date: 17 Oct 2023

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1. Introduction

2. Responsibilisation, Technology and Co-Management of Care in Supported Housing

References