I haven’t got many responses to my posts about care.
It may be they are boring or that people who understand the topic don’t feel I have much to add to their specialist insights, but I wonder whether it’s also because many of us find the issues depressing or intractable.
In an attempt to be provocative I suggested last week that a characteristic of a hypothetical good society would be that the decision to make financial or other major sacrifices in order to provide care to a child or elderly relative would be seen as voluntary, buttressed by social norms and expectations rather than – as it is now – effectively forced on people as a result of inadequate collective provision.
My point was not that people shouldn’t make such sacrifices or commitments but that in a healthy society we would be seen to choose to do so, in part because the development of the future generations and provision to the frail and vulnerable are understood to be in the interests of, and the responsibility of, wider society. Thus the decision to put caring first would strengthen what is sometimes called ‘the economy of regard’ rather than being a forced response to a deficit (lack of public funding or affordable market provision) in the formal economy.
Although we may tend to assume not much can be done about it, at least the major sacrifices that millions of carers are expected to make are sometimes recognised as an inadequacy of the system. Arguably more disturbing is our acceptance of another aspect as being natural or functional; this is the scale of residential provision.
The Care Quality Commission estimates the number of – overwhelmingly elderly – people in English care homes as 375,000. It is estimated that around four in five of these people have dementia or other memory problems. Although there are too many examples of scandalously poor care in homes, we less often discuss the whole idea of warehousing old people in this way. Yet, as this recent report from the Alzheimer’s Society shows, people tend to have very low expectations of the quality of life offered by residential care. It is hard enough for well paid well supported professionals to try to provide the kind of empathy and reassurance loved ones are able to offer, but despite the efforts of the more conscientious providers and managers, residential homes are largely staffed by low paid workers with high rates of turnover.
Surely if an alien from outer space were to visit our society they would be horrified at the effective removal of hundreds of thousands of people from the society into residential warehouses where they are simply managed unto death. The current economic crisis downturn aside we tend to view modern history as a progressive process whereby more people are able to enjoy more opportunities and a better quality of life, but it is difficult to see how the way we treat the frail elderly today can be seen as an advance on the combination of familial and communal provision that would have been made in pre-industrial societies.
As the Alzheimer’s Society research indicates, most of us are very gloomy about the prospect of having ourselves to join the ranks of those in residential care. But instead of this driving us to demand reform based on the kind of life style we would like if we were frail and forgetful, we simply cross our fingers and hope it won’t happen to us.
For the time being I am not intending to write any more of these posts about the problems of our care system. My hope was that demonstrating how many and how profound the problems are might stimulate some insight into how we reframe public discourse away from individual issues and reform proposals and into a deeper consideration of what the care crisis says about us, and how we might need to think differently if we wanted to create a care revolution.
I have to admit that the spark of indignation has not yet lit the flame of enlightenment, but I’m working on it.
Does the following clarification help us better frame the debate over care?
Our care system is in a state of disrepair, bordering on crisis.
Just to recap the main evidence:
- The continual flow of examples of poor care for vulnerable people in institutional settings
- Linked to this the identification of an alleged decline in compassion in caring professions such as nursing
- The worsening local funding situation for social care leaving services restricted to a basic entitlement for the most needy
- Talk of all local government spending being consumed by social care within a few years
- Worsening problems of affordability both for elder and child care exacerbating issues of living standards and work incentives
- The caring sector is overwhelmingly one of low skilled, low paid, low status employment
- Many care activists argue that systems continue to trap people in dependency and disempowerment
- Despite good work from bodies including Participle, NESTA, Shared Lives Plus, we still lack innovations which have the capacity at scale to make a difference to social care productivity and effectiveness
- The pattern of care tends to reflect and exacerbate social inequalities of class, gender and disability
- The continued social isolation and effective invisibility of many carers (including children), old and vulnerable people
- A failure to measure and value care as part the social economy
From such a base line it can seem inconceivable that we might create a care system (by which I mean a social system not just a policy framework) which is:
- Equitable and just
- Supported and fulfilling
- Safe and decent
- Affordable and productive
In a context of rising needs and severely constrained private and state resources the long term continuation of a gap between our care aspirations and the reality is inevitable. However, understanding the scale of this gap in terms of both material needs and political values (the denial of rights and justice) is an important starting point for a deeper debate.
But why is it that the public discourse about care focusses on a series of symptoms of crisis but rarely explores the more fundamental dilemmas and problems from which these symptoms spring?
One is surely the ambiguity over whether care is primarily a matter of personal moral choices or public political choices. Take these three examples:
- The ambivalence in public discourse over the degree to which parents (and particularly mothers) should accept that having children involves making financial sacrifices.
- The sense that whether or not we end up having our economic opportunities and basic quality of life profoundly adversely affected by caring for chronically ill or disabled relatives is something determined by fate and private choice, rather than public policy and social support
- The idea that nurses (or other caring professions) should be expected to demonstrate ‘compassion’ over and beyond good customer care.
In a good care system there may be social approbation for self-sacrificing parents and carers and (in the same way as medals are awarded in the military precisely for doing more than can be reasonably required) for caring professionals who choose to go above and beyond the call of duty. But a system which demands substantial sacrifices be made by carers is one which is implicitly denying a collective interest in and responsibility for creating future generations and caring for the vulnerable.
Whatever we might hope that carers would choose to do in a good system the point is that these things should be choices (and thus in Avner Offer’s terms aspects of the ‘gift economy’ or ‘the economy of regard ‘) not requirements or unavoidable realities.
The point of identifying clearly the gap between a good system and the current system is not simply to generate some depressing and impossible numbers for the funding shortage. As I have argued in an earlier post, the care system is a diamond comprising the market, the state, the family and the community. And, as I also argued, it may be that the aspect of the diamond which has the greatest scope to be enhanced without negative trade-offs is the one that currently receives the least attention, the community.
Disillusionment with Hollywood came in my teens. Like millions of filmgoers I had been thrilled by Alan Parker’s Midnight Express, which told the often harrowing story of the brutal imprisonment of Billy Hayes by the Turkish authorities after he was convicted of trying to smuggle hashish out of the country. I was dimly aware when I saw the film that the Turkish authorities were aggrieved but assumed this was standard propaganda from an oppressive and backward state.
Then I read Hayes’ own account of his ordeal, on which the film was based.
No one could deny that he had a hard time but the degree of license taken by Parker is illustrated in the contrast between the real and the filmic last days of Hayes’ imprisonment. In the film a bedraggled half dead Hayes escapes into the city from his rat infested dungeon hellhole after – as I recall – a violent confrontation with the most sadistic of his jailers. In reality, Hayes achieved freedom by hiding in a fishing boat which was leaving the island open prison on which he was spending the latter days of his sentence. No wonder the Turks – generally presented in the film as sweaty, corpulent sadists – were angry.
I was reminded of my disillusionment reading the adverse commentary on the film Argo. My disappointment with Ben Affleck’s award winning blockbuster was increased further by the contrast with a genuinely wonderful political thriller, Pablo Lorrain’s ‘No’ which tells the story of the campaign to stop General Pinochet winning a referendum which would have given the dictator a further period in control of Chile.
Yet ‘No’ too has been the subject of criticism. Its focus on the marketing campaign has been attacked for failing to recognise the importance of grass roots efforts such as voter registration. I don’t know enough about Chile to make an informed judgement on ‘No’s veracity, but in viewing the films and reading the critiques, there is to my mind a fundamental distinction.
‘No’ has subtlety and complexity. We can understand the ambivalence that Chile’s squabbling progressive parties felt at using a commercial approach to their campaign. We want our hero to win but there is pathos in his victory. Whether his strategy merely popularised the struggle or in some way cheapened it, is a question the director trusts us to reflect upon.
Argo by contrast knows what we want to believe (that the world is divided into good guys and bad guys and the good guys win) and then helps us believe it by weaving what is basically a fictional tale. ‘No’ not only explores the ambiguous line between populism and cynicism but as a film it manages to stay on the right side of that line. Argo never even tries.
This may all sound very subjective but surely there are objective distinctions to be drawn between, on the one hand, looking at actual events from a particular angle and inventing plausible scenes which illustrate genuine issues and, on the other, inventing history simply so that a story can be crowd pleasing while trying to gain unmerited credibility through claiming the story is based on true events?
If a distinction between populism and cynicism can be true of films, can it also be true of political speeches? I have no problem with well-intentioned populism. If David Cameron wants to package up a series of measures (some which have already happened, some which are happening anyway and some which might never happen) into something which looks like he is taking tough action on immigration, then, whether or not such an endeavour succeeds, that’s politics, which is, in part about communicating with the public and showing you take their concerns seriously. After all, no one is hurt if the public accepts a slightly spun package to amount to more than it actually contains.
But can the same tolerance be shown to another aspect of the speech? In several areas – the overall scale of migrant benefit claiming, the use of the NHS by illegal immigrants, and the scale of immigrant take-up of social housing – there was an apparently deliberate attempt to say that the problems caused by immigrants are worse than they actually are. A speech which claimed to have the purpose of reassurance probably increased tension and resentment. Unlike a bit of creative policy packaging, such manipulation may have victims – risking making immigrants feel like pariahs and legitimising anti-foreigner sentiment.
It is not as easy to make a commercially successful film while sticking reasonably faithfully to the messy and prosaic nature of reality as it is to change the facts to fit the formula of a winning plot. It is not as easy to generate headlines and voter support by describing a complex picture as it is by being alarmist and confirming false assumptions. Perhaps taking the hard road is respectively what distinguishes the film maker from the creative artist and the politician from the statesman.
When it comes to political communication I have a tendency to be unduly pious, generally wanting politicians to be more candid and brave and arguing, without any real foundation, that ultimately such an approach will prove to be popular. Perhaps it’s why I could never make it as a politician myself and why many former colleagues found me unrealistic at best and more often a self-righteous bore.
As I lost argument after argument l searched for a clear and defensible distinction between legitimate vote winning and meretricious pandering to prejudice. Perhaps – although far too late – in the contrast between Argo and No I have found the distinction I needed.
In my annual lecture last year I argued that a decline in the performance and legitimacy of institutions along side a weakening of social solidarity had led to individualism being the dominant way in which we think about and pursue change. The problem is not so much individualism per se (like hierarchical authority and social solidarity, it has its weaknesses and strengths as a mode of operation) but that it is required to do too much work in terms of resolving hard problems. For example, as I have also argued, the political establishment continuously and erroneously maintains that the individualistic idea of social mobility is the most appropriate and effective way of addressing social injustice.
The dominance of individualism (which is accompanied by a muted but powerful social fatalism) influences the way we see the world. It becomes hard to know whether individualistic solutions are best or we have simply become more receptive to those solutions.
A few weeks ago David Halpern, head of the Government’s Behavioural Insights Team spoke at an RSA seminar on social networks and values. He said he had gone into his job being interested both in ‘nudge’ based interventions which target individual behaviour – things like asking people to sign a commitment to look for work when they register with a job centre – and asset-based interventions which focussed on understanding and mobilising communities. However, as went on to say, the former had both been easier to measure – using the preferred methodology of randomised control trials – and more productive in terms of generating proven interventions.
I was reminded of David’s comments when listening yesterday to Evgeny Morozov delivering an RSA lecture about his new book ‘To save everything, click here’. For Morozov the capability offered by big data, used in combination with insights drawn from behavioural economics, social psychology and neuroscience, to offer individualistic solutions to problems ranging from obesity to criminality brings with it two major dangers.
The first concerns privacy and intrusion, do we really want Google to be using our smart phones and embedded sensors in day to day objects to learn a huge amount about our behaviour, including our various cognitive and behavioural quirks. By the way, I find it odd that while we would object strongly if a stranger came up to us and told they knew more about us than we know ourselves, most people seem relaxed about a private corporation having such an advantage.
Morozov’s second objection chimes with Halpern’s experience. He argues that the ability to analyse individual behaviour in granular detail and the enthusiasm of the tech community for behaviour-changing interventions based on incentives and ‘gamification‘ leads policy makers to view all social problems as problems of individual modification not social change.
So the capacity of technology, the insights of behavioural science and the weakness of alternative world views interact to drive an ever more individualistic paradigm.
Another example is the tendency to blame the poor for being poor. The myth - peddled by politicians who should and do know better – that a high proportion of the millions who are out of work are inter-generationally long term unemployed and that by implication their problems are ones of character (maybe even genetics?) is not only objectionable but hampers sensible policy making.
On refection, we know that social problem are not all about the decisions and capabilities of individuals and we remain responsive to hierarchical and solidaristic analysis and solutions. Indeed there may be a connection here to the rise of so-called populist parties. As conventional leaders fail to reform institutions and provide new forms of authority, and as policy makers lose faith in social remedies, nationalist and extremist parties seem to offer the only route for our desire for visionary leadership and shared identity.
‘It’s not about you, it’s about us’ may sound like a terrible managerial cliche but it seem to be something we are finding it ever harder to believe about social problems. To tap the full scope for social power and to achieve progressives ends, means not only focussing on the future we might want but on the means we need to get there.
The future health of our society will be significantly influenced by whether ordinary citizens demonstrate greater altruism through volunteering and philanthropy. We need such kindness to increase the resources available to meet social need but also because research suggests that a society that collectively gives more back is likely to be more cohesive and contented. The last Labour Government took various initiatives to boost giving time and money and such signs of social responsibility are central to what the Coalition Government used to refer to as the Big Society. But two recent reports show just how far we have still to go to create a culture of altruism.
There are two key headlines from a fascinating research report on giving produced by New Philanthropy Capital:
- Even among those who regularly donate money only a minority think there should be an expectation that everyone who has the means should give.
- A major impediment to giving is a lack of rigor and communication from charities on the impact of their work and thus the impact of giving.
(If I have read it correctly, the report also confirms that proportionately the rich give much less of their income than the less well-off. This fact is supressed in favour of the much less illuminating one that the rich give more in absolute terms. Presumably the authors didn’t particularly want the headline to be ‘NPC bomb shell: UK rich as tight as camel’s arse in a sandstorm’).
As I have argued in a series of posts on the care crisis in Britain, expanding society’s voluntary contribution is vital to meeting future needs as this is the only source of care which could be grown without significant drawbacks. Last week saw a substantial and well researched report from The Kings Fund on volunteering in health and social care. I say ‘well researched’ but even after all the fine words from various Governments it still turns out that getting a handle on the scale of volunteering is like trying to locate a black cat in a coal hole. Based on simple extrapolation from the last National Citizenship Survey (now replaced by a much less robust set of measures), the authors estimate that three million people regularly volunteer in the health and social care domain, which is roughly equivalent to the work force and about two thirds as many people as provide informal care to family members.
The three key points from Kings Fund document are:
- Overall, and particularly in those institutions which take it seriously, volunteering can make a significant impact on the quality and effectiveness of care, indeed in some areas volunteers add something which is unlikely to be available from paid professionals.
- Yet, in most policies, sectors and institutions there continues to be a failure to develop a strategic approach to volunteering.
- This lack of grip is particularly problematic now as the combination of health reform and the public sector spending squeeze – while making volunteering more important and possibly attractive – also poses major threats to volunteer motivation (for example, volunteers do not want to feel they are being used to fill gaps created by cuts and they are ambivalent about volunteering in the private sector). Government ministers may bang on about volunteering (perhaps in the hope of a nice ‘phone call from Downing Street) but there is little evidence of a concern for it informing their core reform agenda.
While the report’s recommendations are somewhat predictable and technocratic (more strategy, more data, more co-ordination), my eye was caught by this short section hidden away in the middle of the paper:
The complexity of the debate about role substitution is heightened further by the fact that in some areas of care, there is a case for questioning whether professionally led services always deliver the best outcomes for service users and their communities. For example, there is increasing evidence on the effectiveness of peer support in mental health, long-term conditions such as diabetes and for promoting healthy behaviours. Some of our research participants argued that what is needed is a process of radical de-professionalisation, with a central role for volunteers…Changing the composition of the health and social care workforce in this way would be a long-term undertaking and would at times be a source of contention.
The last clause is almost certainly an under-statement, but the question hovers: can volunteering ever fulfil its potential to bring a step change to the ethos and quality of care as long as it is not only marginalised but also seen – almost by definition – as having a subordinate role and status in comparison to the contribution of paid professionals?
Greater altruism is vital and would help build better lives in a better society. But to achieve the necessary step change means profound changes in social norms (starting with the rich), a transformation in the effectiveness and candour of the third sector, and a radical departure from the bureaucratic/professional/commercial culture of our public services.
Such a manifesto poses challenges to all ideological starting points which is probably why the debate sponsored by ministers managers and third sector leaders generally stays in the safe territory of one-off initiatives and warm words.
PS The RSA is encouraging philanthropy among our own Fellows (although you don’t need to be a Fellow to give). We are acting on the advice that donors want to know where there money is going and for what purpose. If you want to know more about our student enrichment fund you can find out here.