The Guardian’s splash this morning focussed on the delayed launch of the Better Care Fund. The Fund aims to encourage improved coordination across health and social care but apparently the Cabinet Office has severe doubts about value for money. This may be embarrassing for ministers and officials but, if there is one thing worse than a bad policy being delayed, it is a bad policy being implemented.
Apart from general misgivings quoted in the Guardian, we don’t know the substance of the Cabinet Office’s concerns, but let me offer three reasons why what looks like a sensible response to an obvious problem might be running into difficulties.
First, the Fund was premised on one of the most commonly claimed, and also one of the least often proved, assertions made in public policy; namely, that spending money in one area will reduce expenditure in another. Hospitals are expensive, risky and anonymous environments and so it is surely in the interests of both public sector paymasters, on the one hand, and patients and carers, on the other, that people should stay in them for the minimum necessary time.
The problem is that cash strapped local authorities have always lacked incentives to help reduce bed blocking and now face eye watering budget cuts. The Fund will transfer money from the NHS to councils on the principle that better community provision for councils would reduce pressure on the NHS, both in long stay wards and in the A and E departments where badly cared-for vulnerable people often end up.
I have heard this kind of spend to save argument countless times not just from public sector officials but from people setting up a variety of social enterprises and charities. So I will let you into an open secret, everyone in the Treasury, and now it appears the Cabinet Office, treats such arguments with intense scepticism. Time and time again such promises evaporate as savings fail to materialise either because the policy doesn’t work or – more fundamentally – because the released capacity in one area is immediately filled with new demand. As what is ostensibly a spend to save scheme, the Better Care Fund would have immediately aroused the suspicions of any seasoned policy analyst and in this case those concerns would be loudly echoed by NHS commissioners and providers threatened with having to hand over money to their local council today in exchange for jam savings tomorrow.
Second, I suspect size matters. There are some structural ways one might address the health and social care divide, most obviously putting certain NHS services under the control of local authority social care departments or vice versa, and there are lots of smaller scale innovations which can and have made a difference in particular cases, but the £3.8 billion Fund may have suffered from reverse Goldilocks syndrome: too big and expensive to be genuinely innovative but too small and short term to achieve system change.
Third, when a problem is obvious, bad and persistent the tendency is to think that what is needed is simply more determination to solve it – in this case incentivised by cash. But when a problem is obvious, persistent and bad it also tends to indicate something else – we may be failing to grasp its nature and how difficult it is to solve.
The other day I came across an example of this in a different part of the social care jungle. I was being told that teenage children who fall into the care system (a system which is expensive and has poor outcomes for older children) have very often been seen multiple times by local authorities and other agencies. The obvious point, and one we often hear in tragic cases of neglect, is that none of these interventions grabbed the problem and solved it once and for all. The answer is surely concerted decisive interventions earlier on. So far, so obvious, but this view of the problem is conditioned by the starting point – those who have been failed. What about evidence as to the general efficacy of earlier interventions?
If, for example, we found out that 90% of youngsters subject to an earlier and cheaper intervention (some form of parenting support, for example) had not re-entered the system, we might deem this value for money even though 10% fall through the net. Also, if a system focusses on more intensive interventions the consequence might be that fewer youngsters get any kind of help and that we over-intervene with youngsters who only needed a small helping hand. Thus the case for what seems a more effective and economical solution (one big intervention rather than lots of smaller ones) may not be as open and shut as it seems.
I suspect that bed blocking may be a similar example where, perhaps, most frail people do successfully exit to the community while the few who don’t have particular characteristics such as complex conditions and needs, and a lack of informal support. If those who are bed blocking are the hardest cases then neither the projected savings nor the better outcomes of community care will be as clear cut as they first seem or as ministers – who are desperate to believe they can have a decisive impact – have been led to believe.
There are no doubt lots of bad reasons why the launch of the Better Care Fund has been delayed. There might also be some quite good ones.
I have been trying to use my preferred way of thinking about human motivation and social power to develop the RSA’s emerging world-view, ‘The Power to Create’. In this regard I am grateful for an idea given to me by public intellectual and social innovator Charles Leadbeater (who will be speaking soon at the RSA about his new book ‘The frugal innovator’.
Charlie tells me that from his own direct observations he has come to the conclusion that the most innovative and successful organisations are ‘creative communities with a cause’. The potential synergy between my simplified application of cultural theory and the goal of greater creative capacity is obvious (well, to me, at least): Broadly, the three ‘c’s in Charlie’s phrase line up respectively with the three sources of social power in my account; the individualistic (creative), the solidaristic (communities) and the hierarchical (cause).
A concern with The Power to Create has been its lack of ethical substance; looking out on the inequalities and wastefulness of modern society the question asked is ‘whose power to create what?’ A focus on the role of human drives in the effectiveness of organisations, people and places doesn’t solve this problem, but it might help.
Going in reverse order, consider the critical polarities for each drive:
The production and maintenance of rationality is often the role assumed by leaders and the hierarchical systems over which they preside. But in his study of bureaucracies (of which he was generally a fan), Max Weber made the powerful distinction between substantive rationality (directed at ends/outcomes/values) and procedural rationality (directed at means/procedures/rules). Organisations are established to pursue substantive rationality but over time, as they become institutionalised, procedural rationality often starts to dominate.
By the idea of ‘cause’ Charlie’s description of the most effective organisations implies leaders who maintain a focus on substantive (value) based rationality rather than procedural (process based) rationality. Interestingly, there is growing emphasis in debates about corporate responsibility of the ideal of purpose driven organisations.
People on the left often assume that solidarity is their kind of thing. But this human drive – based on shared norms, identity and values – is characteristic of racist populism as well as workers’ cooperatives. The key polarity here may be between ‘solidarity for’ and ‘solidarity against’, both in term of identity (an expansive versus an exclusive bond) and mobilisation (cooperation to develop solutions versus cooperation simply to mobilise protest).
The context in which Charlie uses the word ‘community’ implies an expansive idea based on a constructive activity.
The Power to Create is an alternative to a previous, less stirring, definition of the RSA’s mission, namely ‘enhancing human capability’. A focus on capability points to the key polarity when it comes to the individualistic drive. This is between the fulfillment of individual appetites (for stuff, power, wealth or whatever) versus a notion of human development. There are many versions of the latter and RSA folk are particularly keen on that of Robert Kegan but the key point is that this is an idea of individual aspiration linked to self-discipline and self-knowledge as well as self-expression.
By using the descriptor ‘creative’ the implication of Charlie’s phrase is that the individualist drive in the most effective and innovative organisations is directed to personal growth and pride in craft rather than success measured only by income or promotion.
For me the most intriguing aspect of the Power to Create is that it implies two distinct but overlapping ideals, one with a primarily idealistic rationale and the other responding to more practical imperatives: first, citizens being able to create the lives they choose; second, an economy and society characterised by mass creativity.
The kind of creative organisations, places and societies needed to pursue both these goals would, according to this account, tend to exhibit leadership based on substantive rationality, forms of solidarity that are inclusive and constructive, and a developmental model of individual aspiration.
Certainly, as we look at the largely depressing tableau of modern politics and public discourse, to make the case for idealistic leadership, for forms of belonging which are generous and optimistic and a model of human success which is to do with being rounded productive citizens rather than wealth-hoarders or consumers – well, it seems pretty revolutionary.
I agree with Adam Lent. There is no fundamental reason why the accelerating capacity of new technology to undertake tasks previously the domain of skilled humans should lead us to be pessimistic about the prospects for social progress. All things being equal, rising productivity driven by technological advance provides the basis for sustained economic growth and sustained economic growth (especially if that growth is focussed on the quality not the quantity of production) should mean more people being able to pay each other to have their needs met and desires fulfilled.
But, of course, all things are not equal. As Andrew McAfee and Erik Brynjolfsson recognise in ‘The Second Machine Age’ the impact of technological change both reflects and reinforces aspects of the social arrangements in which it appears. Neither economic nor technological determinists are right, as Evgeny Morozov has argued, different technologies interact with social reality in ways which reflect specific aspects of each. For example, email is functional for bureaucracies while social media tends to be disruptive and Twitter can be effective both as a way of mobilising protest and as a means to monitor dissent.
Thus the biggest danger of the coming third industrial revolution/second machine age (or whatever we choose to call it) is that it has the potential to map onto and further widen inequality in an era when national Governments seem particularly powerless to intervene on behalf of the greater good. Imagine if Google had been invented in the 1950s (yes, I know that was before the internet but stick with me): It would have been assumed that such a ubiquitous and essential service which makes its money largely out of expropriating other people’s labour (content) would have been at the very least highly regulated and taxed and more likely brought into public ownership.
Among the characteristics which lead McAfee and Brynjolfsson to believe that intelligent computing power will further widen inequality are these: it is only the most creative and ‘special’ people who will still have something to offer than robots don’t; and digitally based innovations can spread very quickly making huge monopoly profits for inventors and investors until another innovation comes along to make another killing for another group of super clever or super rich individuals.
Another related factor concentrating power and wealth are network effects which mean that the bigger the market share achieved by a platform, the more effective it is and the more able it is to withstand and buy out competition (think of the respective dominance and scope for rent-seeking profits of Google, Facebook, Amazon, Twitter and Kickstarter).
Without action technological change will reinforce already wide inequality. Compare this with the middle of the last century: the inventions of the first machine age – domestic electricity, motor cars and white goods – achieved ubiquity among Western consumers at a time when a much higher proportion of economic growth was recycled into the income of ordinary workers. Now – as Thomas Piketty eloquently argues – the proceeds of growth are being grabbed and hoarded by the already wealthy.
So, whilst Adam is right that we should reform education and pursue other policies to prepare our populations for the challenges and opportunities of the second machine age, these challenges will be much harder, and opportunities much fewer, unless Governments (working at home and internationally) can develop the legitimacy, confidence and know-how to ensure the benefits of the next technological revolution are fairly and wisely distributed.
Which reminds me of another of Adam’s blogs, this one on Moses Naim’s analysis of the decline of big power, particularly that of the state. The American sociologist Daniel Bell once argued that in the modern world the nation state would come to be seen as ‘too big for the small things in life and too small for the big things’. I have tended to think of this as being about the spatial dimension of governance; the need for greater devolution to localities, on the one hand, and greater international collaboration, on the other, but it is more deeply a point about power.
I have repeatedly argued that central Government and its traditional policy tools are becoming ever more blunt and dysfunctional when it comes to social policy. Yet we desperately need the unique democratic authority of Government to tackle some of the biggest problems we face; on climate, inequality, infrastructure, regulating finance, and global security. When Piketty argues for a global wealth tax or McAfee and Brynjolfsson join the ranks of those who support a minimum income guarantee, it is not so much that people object to the proposals as that they have little faith in Government to be able to enact them successfully.
All of which leads to me to conclude that part of the RSA’s pursuit of what we call the ‘Power to Create’ (releasing the creativity inherent in all of us) must be about 21st century statecraft. Technology is the most powerful single force in the modern world but its impact depends to a large degree on the choices we have made and the choices we will make. Democracy is the way we make those choices at a collective level. Unless democracy works better in twenty-first century conditions then there is no guarantee that technological progress will beget human progress.
It was more than slightly intimidating earlier this week to host an event with David Harvey, one of the world’s leading Marxist thinkers. Nevertheless listening to the great man and reading his book I was reminded of why – although there are many powerful aspects of Marxist analysis – I have never been attracted by the whole world view.
It comes down to human motivation: In essence Marxists tend to blame what they see as the most regrettable aspects of human behaviour on the capitalist system. So, for Harvey, capitalism relies upon and inculcates blind greed among the capitalist class (exhibited, for example, by the efforts made by the very rich to avoid their tax obligations) while fostering a combination of mob consumerism and bovine acquiescence among most of the rest of us. Conversely, Harvey’s happy, enlightened post capitalist society seems to rely upon the emergence or a much more benign human psychology. Indeed Harvey is explicit about the importance to his case of a belief in the perfectibility of the human spirit – it is why he abhors the depredations of capitalism and why he believes in a radical alternative.
In contrast, I believe human motivation is both more constant, in that the same features and vulnerabilities express themselves – albeit in different forms – whatever the social context, and more complex in that – with Freud – I see inherent tensions playing out in the human psyche.
Crudely superimposing very basic elements of cultural theory and the Freudian account of the personality, I suggest we have three core drives: the pursuit of pleasure (roughly cognate with id, freedom, individualism), the pursuit of power (roughly cognate with ego, progress, hierarchism); the fulfilment of duty (roughly cognate with super-ego, universalism, solidarity).
While I am only too ready to believe that consumer capitalism encourages an idea of pleasure which is both insatiable and narrowly materialistic and that it therefore tilts the balance of human nature in a particular, problematic, direction, I neither think the inherent conflict between our core motivations is a characteristic of capitalism alone nor that this conflict will ever be fully transcended.
This takes me beyond a fairly well-rehearsed and probably simplistic critique of the Marxist account of human nature to the debate in the RSA about the set of ideas we call the Power to Create; ideas which might ultimately frame the major part of our work.
A concern in our internal discussions (soon we aim to open that discussion much wider) has been that the focus on creativity can seem individualistic and ethically empty. This is why we stress inclusion (releasing the creativity in everyone) and responsibility (creativity for the common good) alongside creativity per se.
Going back to my triptych of human impulses, creativity can be seen to reflect two impulses – the pursuit of pleasure and power – but not the third – duty and responsibility. For example, does a focus on creating new things imply complacency about environmental sustainability or is it incompatible with the idea that human beings should prize a capacity for stoicism, quiet reflection and humility?
There are two responses to this concern: First, creativity can certainly be applied to questions of ethics and duty (this is the inspiration for much social enterprise); second, creativity can be about how we achieve a higher trade off point in the eternal tensions between our desire for the good life, for achievement and status, and to be virtuous. Creativity can thus be linked to Robert Kegan’s idea of self authorship as the highest stage of human development.
It may indeed be the ideology of consumerism that leads us sometime to conflate the idea of enhanced human agency with a narrow idea of self interest and personal ambition. Yet far from greater self mastery (a belief that we can create the future we choose) being seen as a way for the individual to free themselves from their natural and social context, the ideal should be that it leads to a deeper awareness of our essentially social nature our relationship with the natural environment and to more fulfilling and benign ways of managing the inherent tensions between our different human needs.
How should we carry the past into the future? This important question lies, often opaquely, behind personal, political and cultural dilemmas. Without the past we have no identity, we are not human; but the past can also be an invading army colonising our future and mercilessly wiping out the people we might have chosen to become.
Writing back in the 1950s Alan Watts’s ‘The Wisdom of Insecurity’ drew on eastern philosophical traditions and modern psychological insights to issue a rallying call for living in the present:
‘There are, then, two ways of understanding an experience. The first is to compare it with the memories of other experiences, and so to name and define it. This is to interpret it in accordance with the dead and the past. The second is to be aware of it as it is, as when in the intensity of joy, we forget past and future, let the present be all, and thus do not even stop to think, ‘I am happy’
Watts does not advocate forgetting or ignoring the past but that we should be mindful of the way in which, in the very act of meaning-making, we give the past dominion over the present and preclude the power and joy of unmediated experience.
While the feeling of transcendent ‘nowness’ may be rare to those of us who have not chosen the path of committed meditation we can more prosaically perhaps agree that in life’s journey the past should be a guide book of useful information, suggestions and stories rather than a rucksack of rocks.
Think also of heritage and place. There is a drive to build more new towns but whatever benefits starting from scratch might bestow our ambivalence about the concept reflects the sense that for a place to have identity it must have a past.
An RSA project is looking at the role of heritage in local social and economy strategy. It suggets civic leaders are aware of how the past provides identity and distinctiveness (dare I say ‘brand’) and in a nexus for civic engagement and social connection. Yet, too often, the heritage sector defines itself in terms of the protection of old stuff, forgetting that if heritage has no resonance beyond the historical it may survive but be inert.
The best way to protect the past is to think deeply and creatively about its contribution to the construction of a future sense of place. By choosing to be a site of contestation about identities and choices, heritage can secure its place as a social asset.
Then to politics: Thomas Piketty’s monumental work ‘Capital in the in the 21st century’ is rightly being seen on the left as one those rare debate-changing works. In it, the French economist argues that with the exception of the early and middle part of the twentieth century (when war, population growth and social democratic policies combined in a very particular way), earnings from assets have outstripped economic growth and thus earned income. Growing inequality between those who have assets, and are able not only to enjoy their fruits but grow them further, and those who do not is endemic to market economies. We mistook the exceptional cycle of the twentieth century as a trend but now we seem set back on the road to nineteenth century levels of profound inequality. Combine this with modest levels of long term growth and the prospects for those without assets are grim.
Piketty’s work raises many provocative questions and left of centre blogs are buzzing with them but one of the most important concerns time:
‘ …inequality expresses a fundamental logical contradiction. The entrepreneur inevitably tends to become a rentier, more and more dominant over those who own nothing but their labour. Once constituted, capital reproduces itself faster than output increases. The past devours the future’
And so to David Cameron’s apparent commitment to make a major cut in inheritance tax a priority for a Government in the middle of a deep austerity programme. What is it that we want to pass onto future generations? Surely love, self-worth, some sense of the responsibility and honour of standing on the shoulders of past generations. There is no reason why part of this legacy should not be expressed materially.
That parents do all they can to help their children thrive, that adult children strive to provide dignity and care to older generations, and that at death we pass on – if we can – assets which might provide our loved ones with opportunities or some resilience to misfortune; these are parts of the familial world we should honour and protect. But should the opportunity to succeed become a passport to entrenched privilege, should something to fall back on become a feather bed for the failed or feckless? Most of all do we want the result of yesterday’s races to become an insurmountable handicap system for tomorrow’s?
How does the past live in the future? It turns out this question is everywhere. Perhaps we should think about it more deeply and more consistently.