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11.1 Introduction

The recent comprehensive review of developments in care of the elderly since the publication of The Years Ahead report (1988) is critical of the slow rate of progress towards the development of a genuinely community-based approach to the long-term care of dependent elderly people (Ruddle et al, 1997). While there remains a general consensus that the long-term care of dependent elderly people should be located in the community, which is reiterated in this plan, not enough has been done in recent years to develop community care services in a way that would significantly improve the quality of life of old people living at home. There is uniform agreement that a major gap exists between the needs of dependent elderly people and service provision. This plan has outlined a

strategy for meeting the needs of people with dementia in this country. We cannot, however, rely on increased public spending to solve all of the problems in this area, given the continuing constraints on social expenditure originating in our adherence to, and commitments arising from, the Maastricht criteria for Monetary Union. We will have to explore innovative ways of developing entrepreneurial supply-side responses to the problem of social need in the area of dementia. This chapter highlights the potential of the social economy in bridging the gap between need and existing provision of services for people with dementia living at home.

11.2 The nature of the social economy

The gap between the needs of people with dementia and the public and private resources available to meet those needs has focused attention on the possibilities of bridging that gap through the development of the social economy. The social economy is difficult to define with different groups using different definitions depending on the particular context at any given time. Most definitions include some combination of the following to describe social economy activity:

community ownership, local control and benefit, decentralised, people-centred, models, and social objectives.

The social economy is most relevant where market failure exists, but the state cannot, or will not, intervene. In such circumstances, needs and demands arising from the market failure are met through community, voluntary, or co-operative forms of organisation, rather than through conventional public sources. Latent needs are transformed into effective demand through local community-based

innovative responses to the problem of provision. Thus delineated, the social economy is related to the concepts of the 'third sector' which comprises the voluntary, non-profit, and co-operative sectors. For people with dementia and their carers, need exists in relation to community nursing services, home care services, day care services, respite care services, and transport to facilities. The social economy has the potential to respond to need in all of these important areas.

Social entrepreneurship may be the key to expanding community care provision in the future. Social entrepreneurs are an important source of social innovation. They identify social need, but more importantly they identify new ways of addressing these needs, making use of existing social capital to create new forms of supply. Finding ways to stimulate social entrepreneurship at the local level will be an important part of any new strategy for dementia care in this country. Equally important will be strategies to stimulate demand for any new services from patients and families, and from the state. Innovation on the supply-side will have to be matched by innovation on the demand side if community services for people with dementia are to be expanded.

There is a dearth of information on why some communities are better than others in developing social entrepreneurs and innovative projects within the social economy field. Civic leadership may play an important role in

developing the social economy. There are also indications that the previous involvement of community groups in training and education projects may provide a fertile ground for the subsequent identification and development of innovative social projects. Most of the social economy experiments have so far concentrated on work for females within the social care sector. For the future, seed funding will be required to encourage social entrepreneurship within a broader range of activities and people. This funding could take the form of capital grants, start-up grants, loan/credit facilities, or it might be confined to help with information gathering and training supports. Training and managerial programmes for providers will certainly be necessary, if opportunities are to be realised and exploited. A legal framework will also have to be developed if organisations working in the social economy are to become fully integrated with existing statutory providers of social services. This will involve the

establishment of social care contracts between the health board and local providers.

11.3 Demand and supply issues

While there is agreement that genuine need does exist among older people living in the community, the critical question is how to transform that need into demands which can be met within the social economy. To some extent, this

depends on the willingness of care recipients and their families to pay for the services provided in the new social economy, since this will determine the level of state support required for any new initiatives. Willingness to pay is, of

course, influenced by the amount of income available to people. For many elderly people, and their immediate families, the amount of money that they have available to spend on community care services which are not currently being provided by the health board is very small, even allowing for recent improvements in the income position of older people in this country. If

consumer resistance to charges and personal payment is high due to inadequate income, then demand may have to be stimulated by third party agencies through the use of mechanisms like designated vouchers for social services, thereby offsetting some of the cost for clients. Home equity schemes may also play an important role in the development of the social economy through the release of funds tied up in housing assets. The funds released from such schemes would allow older people who wished to remain in their homes the opportunity to buy in home care facilities and services that would make living at home much easier.

The social economy contains the potential to address some of the social care problems facing people with dementia and their carers. The development of both sides of the social market will require careful nurturing if progress is to be made. As part of this development, the institutional rigidities associated with existing forms of social services provision will have to be tackled. Currently, social care production is, by and large, controlled by the state, and administered through the health boards. This control exerts a powerful conservatism on the organisation of social care and serves to dampen any sustained attempts at innovation and development by local and community groups. If progress is to be made in meeting the needs of dementia sufferers and their carers, the

hegemony that has been established by the state in the area of community care provision must be diluted. Partnership between the health board and local providers needs to be developed and nurtured through the appointment of development officers in each health board to foster co-operation between the two sides. This officer could explore the capital and financial needs of the social economy sector and identify areas where the sector could make a contribution to meeting the care needs of people with dementia. Given the enormous gap between need and provision in this country, and the success of locally based projects elsewhere (Gibson et al, 1996) now is the time to think about new ways of providing social care services and new ways of financing that provision.

32. We recommend the development of the social economy and the nurturing of social entrepreneurship at a local level as a means of meeting the needs of people with dementia and their carers in a flexible and innovative way.

11.4 Conclusion

The social economy contains the potential to make an important contribution to the community care of people with dementia. At the moment, the degree of support for locally based social care projects varies between health boards and even within health boards. The allocation of funding for social economy production is arbitrary, and operates on an ad hoc basis, leading to frustration among community groups seeking to integrate their services with existing statutory provision. Local community groups can meet some of the needs of people with dementia but they require consistent and medium-term funding arrangements in order to develop services. The negotiation of social care contracts between local social economy producers and the health board is the way forward in this area. Social entrepreneurship is the key to further

developments in the social economy. Entrepreneurship can be nurtured by initiatives in business and management training for potential entrepreneurs, seed capital funding for pilot initiatives, and start-up capital grants for projects

meeting specific social economy criteria in the area of dementia. These initiatives would encourage new forms of production to deal with the many gaps that exist in the provision of services for people with dementia.