Here is an extract from a speech given yesterday by Liz Kendall Labour’s shadow spokesperson for care and older people:
Our goal must be to create a new care covenant between citizens and the state, involving all parts of our society and economy. This covenant should be based on the principle that care is a shared responsibility – its risks and benefits are mutual and should not be left to individuals and families to shoulder alone. It must be grounded in values of dignity and respect for those who need and provide care, ensuring older and disabled people and their families have the same choices and chances to live the lives they want as any other section of society.
And it must seek to strengthen mutual care and support within our families and communities, as well as through care services
Fine words, as my grandmother used to say, butter no parsnips. But it is good to see an emphasis being put on values, mutual care and shared responsibility as well as Government policy. As I have argued here before, we need a ‘whole system’ reform of care – something which involves attitudes, behaviours and norms as well as policies.
Yesterday I interviewed the philosopher Michael Sandel for the next edition of the RSA Journal. We discussed his book ‘what money can’t buy’ which has just come out in paperback. In it he bemoans the ‘marketisation’ of more and more areas of life evidenced, for example, in poor children being bribed to study or sports memorabilia being turned from personal objects collected by fans to a billion dollar mass market. His objection to such practices lies in the way they exacerbate inequality.
The more things that are paid for, the more difference having money makes to people’s lives. Take the example of ticketing. If the criterion for access is a willingness to queue early or long, the tickets will tend to go to the most passionate, but if the rich can buy tickets whenever they want from on-line sites, wealth rather than passion becomes crucial.
Sandel also worries about the way financial incentives ‘corrupt’ motives and meanings. If we bribe children to read, do we reinforce the idea that reading is onerous? If we can pay for a footballer’s autograph, it lacks the intrinsic value which we would attach to something we had collected ourselves in a memorable encounter or just standing in the rain for hours.
Bringing together Michael’s analysis and my interests, we had a fascinating conversation about care. This is surely the most important example of the way the value of something changes when it is marketised. The very idea of care contains within it a notion of emotional commitment. Yet, however much we might teach nurses how to be compassionate, we cannot get inside the heart of someone who is paid to care and force them to experience the feelings that we have when we care for a loved one and which we want to believe lead loved ones to care for us.
Michael reminded me of a famous article from 2001 by Arlie Hochschild called ‘The Nanny Chain’ which ponders what we are doing to people and relationships when immigrant carers are paid to look after middle class children and use their remittances to pay a different stranger to look after their own children back home.
In terms of Sandel’s idea of corruption, consider the contrast between the value we place on care in the private and public domain. In the former we say that nothing matters more than the welfare of our loved ones. We give and receive care as part of a web of reciprocity which goes towards defining who we are as social beings. But in the market, care is low status and low paid. Might it be that the low value ascribed to paid care might corrupt the status of voluntary and familial care, adding a loss of self-worth and status (and influence) to the other challenges of being a carer?
To argue that the socialisation and marketisation of care may be problematic is difficult. It might sound like a suggestion that there was a golden past of unlimited compassion, or a failure to appreciate the radically different conditions created by population ageing and female employment, or – worst of all – an attempt to force care back into the home and onto the shoulders of unpaid women.
Politicians are under pressure to come up with solutions. Labour is putting its emphasis on the need to join up social and health care commissioning and perhaps underestimating the reasons why this is very hard to do. But no reconfiguration of spending or services is going to be enough to resolve the care crisis. Liz Kendall is right: we must explore care as part of our lives and our society as well as a particularly intractable set of funding and policy problems.
I have written a series of posts:
about the care crisis, what it comprises, why it is worsening and why it is hard to remedy. Today, in the last of the series, I suggest four sets of ideas which might together provide a platform for a long term care strategy.
As I said in my last post, we need our leaders to recognise that there is a care crisis, not simply a crisis for government and policy but for society, our norms, responsibilities, and expectations. We need to set out an ambitious ten year plan to take us to a new care settlement in 2025 (roughly coinciding with the peak of the baby boom bulge in elders). In essence this is about guaranteeing more dignity and support for care recipients and carers but we also need to assert a core aim of policy as to make it easier and less disadvantageous for people (and this should not be taken to mean mainly women) to provide care to their own loved ones, rather than paying other people to do all or most of it.
We must use existing spending on older people to liberate funds for specific and guaranteed improvement in care. The other aspects of my strategy are primarily about using resources more wisely and generating new commitment and effort to improve care, but nevertheless, any shift in direction will involve transitional and on-going new costs. But these costs must not come from younger generations, which, as a number of people including David Willetts have argued, are already in many ways facing a much tougher situation than those who came before them. So new funding for care should come from wealth testing some universal benefits for older people, from further reducing tax breaks on pensions and by going further than the Coalition’s initial step to increase inheritance tax levels.
We must – and this is hardly an original thought – achieve a better integration of health and social care and public health interventions. Everyone from Andy Burnham to the recent House of Lords report argues for this which suggests the barrier is less principle and more implementation. My solution – which may be simplistic – would simply be to transfer the budget for commissioning all health care for people over seventy and registered as disabled, apart from accident and emergency and elective surgery, to local authorities on the strict condition that, as commissioners, councils cannot also be service providers (for either health or social care).
We need a powerful publicly funded but independently governed agency/platform called something like ‘We Care’. The service would oversee my proposed ‘national care experience’ through which all young people between 14 and 19 are expected to undertake a good quality hundred hours care placement. The service would oversee or incorporate Skills for Care and work to accelerate the development and take up of care apprenticeships particularly at level three and above. In time, all workers in the sector would be expected to be on, or have completed, a level three care apprenticeship or equivalent training package. ‘We Care’ would also spread good practice and innovation and, particularly seek to take what works to scale (possibly through a strategic partnership with NESTA and the Big Lottery Fund). Particular emphasis would be placed on the way professional care services in the public, private and voluntary engage and develop volunteers. From the outset ‘We Care’ would have capacity to work with successful UK care providers to encourage them into international markets in what is a growing sector worldwide. ‘We Care’ would also advocate a wider policy and societal sensitivity to care needs, for example in the design of products, services and housing.
Because the care crisis is so huge and multi-faceted we need a strategy with all these elements; honest and brave leadership, new social norms, fair funding, fundamental service reconfiguration, institutional innovation, strategic co-ordination. In these sceptical, anti-statists, times there isn’t much appetite for grand plans but incrementalism simply won’t move us from an already unacceptable care situation which is only set to get worse.
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.
At the risk of being repetitive, I keep coming back to the Olympic Games as a vivid example of clumsiness. To repeat (again) the idea of clumsy solutions (developed by adherents of ‘Cultural Theory’) lies in the attempt to combine the three basic forms of seeing and exercising power: hierarchy, solidarity and individualism (there is a fourth – fatalism – but it’s not so relevant to this specific argument).
The success of the Games lay in strong and effective hierarchical leadership, the powerful solidarity of national pride and the Olympic spirit, and, of course, the enthralling efforts of individuals competing to be the world’s best. Rarely, if ever, are the ingredients so richly available as they were for London 2012, nevertheless to see a nation prone to scepticism and pessimism amazing itself, and impressing the world, with its capacity for engagement, mobilisation and collective joy is to get a glimpse of the kind of step change this alignment of forces can enable.
As I said earlier in the week, as a motivating force the Olympics started with all sorts of unique advantages, but rather than making the best the enemy of the good, we should seek to learn its lessons. Take the issue of care for older people, which I am glad to see the Government is promising now to address in next year’s spending review, is there anything to carry over to such a tough issue from the exuberance of the Games?
The first might be to set an inspiring goal. Instead of presenting elder care as a depressing problem that we can only hope slightly to mitigate, how about a celebration of the virtues of long life and a population of all ages, linked to the vision of England as the best place to grow old in the world?
Second, we could learn from how Games organisers derived power from the simple imperative of having to deliver the Games on time and according to the promises made when winning the bid seven years ago (we may have quibbled about Olympic transport lanes and officiousness over logos but in the end we knew there was no alternative). So, the Government might consult on an absolute commitment to deliver a particular outcome by a particular time (say reducing by half the proportion of people over 80 who are consigned to institutional care). Having won support for the goal ministers would then have a mandate to make tough decisions and stick to them.
Third, there needs to be valued role for us all. In the Olympics there was the splendid volunteer force, but also every fan with a ticket felt privileged and expected to shout their heads off, and even the rest of us knew we had to enter into the spirit of it (even my mum who HATES sport got quite excited). So an Olympic approach to making England great for frail older people would be one in which we could all feel we were playing a useful role; social care professionals, carers, volunteers and all of us committing to being more positive about old people and old age.
Finally, can there be anything in normal life even remotely as inspiring as the individual pursuit of medals? Perhaps not, but as well as the right financial incentives to insure care needs, a individualistic component to a plan might involve a message crafted and promulgated by older people combining a demand for dignity and respect along with a focus on what all of us can do to put off the time when we need care, or to be better prepared for having those needs or meeting them in loved ones. A loose analogy might be with the way the gay community responded to AIDS through a message of pride and self help. Such a narrative might inspire the independently-minded baby boomers now entering retirement.
There are, of course, lots of riders to attach to the ambition of an Olympian plan for population ageing. It is a challenge that will last a generation not just two weeks (no government can credibly have more than small handful of such transformational goals at any one time). My high level long-term strategy still leaves a myriad of tough policy issues (including the crisis of care facing us right now). But the point remains: whatever the scale of the issue, to make a big difference in a challenging context we need to align bold leadership, strong solidarity and individual aspiration. Maybe if we did so we could be the envy of the world for something a little longer lasting than the Games.