CHAPTERS
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Our public services are dominated by ‘old power’ ways of doing things: designed over the past hundred years to match very different needs, expectations and delivery systems. While there has been piecemeal reform and change, the fundamental assumptions are seldom challenged. And yet, for most of us at some times in our lives, public services have a powerful impact on how we live.
Designed during the 1940s and 1950s, our health and social care systems reflect the mass-production top-down models of their time. In the early years, the hierarchy was clinical and professional and patients were seldom heard. New Labour set out to introduce the efficiency we expect in private services into the public sphere, but in the process they at times downgraded the importance of social values such as kindness and care. As more and more private sector ‘efficiency measures’ were introduced, even the clinicians and professionals felt as if they were cogs in a machine.
As Hilary Cottam points out, our benefits systems have been designed to keep people out, rather than invite people in43. Social security which, as the name suggests, was originally intended to ensure that no-one went without help, rested on a system of reciprocity, but has now been whittled down to a bare minimum. As social security became Universal Credit, what was left of the humanity in the system disappeared. For many people without constant access to computers, or who struggle to cope with complex questionnaires, benefits can be heartbreakingly inaccessible, as shown in the film “I, Daniel Blake”.44
Our care system in particular is recognised as underfunded and unable to cope with the ageing population. But more money, on its own, is not the answer. Care is something we all give and take. Family, friends, the public sector and community support are inextricably interwoven. An approach which simply sees care as ‘a state service’ like any other fails to pay attention to the human relationships involved. We need to think differently.
Brian Cox distinguishes between social care as an industry and social care as a system. 45 The social care industry treats care as a ‘product’, offering a limited and traditional set of services based around physical tasks and buildings. As help in the home has dwindled to almost nothing, the industry is dominated by residential care and institutional solutions. Mostly privatised, the market philosophy leads to a sector that is fractious, competitive and divided.
Good social work theory stresses the need to advocate for people and enable them to find their own solutions and support networks. But the current system turns social workers into ‘gatekeepers’ and ‘assessors’ driving them to work within narrow boundaries. A focus on cost reduction has led management to shrink the time staff spend with each frail person to a bare minimum, meaning that care workers have to rush through their tasks without time to listen or chat, or to offer the little services that give comfort or confer dignity. “Keeping things professional” is code for “keeping things impersonal.” Since care is always a relationship, these policies sentence vulnerable people to harsh and lonely lives. Without understanding this, the idea of creating a ‘national care service’ might simply create a 1940s style ‘nationalised industry’ that does nothing to change the way care works.
If, in contrast, we see social care as a system, we situate it within a wider range of human activities and relationships, built on mutuality, love and wider needs. Social care would be seen as a source of additional support to families, individuals and communities to sustain normal lives. Brian Cox characterises a system of care that embodies the qualities of ‘new power’ as a ‘gas’ – something that permeates our lives, rather than as a ‘solid’ – something concrete but rigid, to be given.46
It is in the social care system that ‘new power’ alternatives have blossomed. The personalised budgets introduced by the last Labour government, the sustained campaigning by disabled adults and a greater emphasis on normalisation has led to some amazing community organisations, such as Social Care Futures, Think Local Act Personal and thousands of small local groups and organisations organising the care they need for themselves.
Local authorities and community-based organisations are at the forefront of rethinking ways to make care services more human, more receptive and more equal.
In health, the continual growth in demand and financial constraints have driven a similar focus on efficiency rather than care. As Madeline Bunting points out “bureaucracy has accumulated in response to every scandal and to the pressure to increase efficiency so that “new forms of management, audit accountability, inspection and regulation have generated a vast edifice of technology which eats into precious time, leaving little space to build relationships”.50 The system relies on the selfless dedication of nursing and clinical staff and, even before the pandemic, there were multiple reports pointing out that staff numbers have reduced to unsafe levels. Burnt-out and rushed staff struggle to offer kindness or dignity. Often the best care is offered as the last resort, in hospitals, intensive care and A&E, but shortages of GPs and staff and constant squeezing of costs means that our preventative and day-to-day care systems are perilously brittle.
There have been numerous, hopeful experiments at a local level in healthcare, using new power approaches, which point to a better way to care. There is some hope that the latest developments of neighbourhood working linking GPs to local community and voluntary projects and to council services could offer a more decentralised approach to integrating care. Over the past fifty years, experiment after experiment has shown how health and well-being can be improved through holistic care in a community setting. But every time cuts are made and another management reorganisation is imposed, these experiments are the first to be shut down. The old hierarchical system seems to be immensely good at reimposing the old ways of doing things despite the proven advantages of some new power approaches.
In mental health, the contrast between new and old power approaches is at its starkest. We are seeing a huge growth in symptoms of mental ill-health. Old power approaches start with a clinical diagnosis, measuring certain threshold levels of distress before help can be offered, and then prescribe a ‘fix’ – often involving drugs which themselves have side effects. But some mental health professionals worry that we are seeing the medicalisation of ordinary human grief and pain. James Scurry writes about how, when people find their daily lives intolerable because of past or present trauma, poverty, homelessness or bereavement – the stress on the body, and the mind, becomes unendurable.51 Anxiety and depression, especially, may be signs that something is badly wrong, not in the individuals but in the society that neglects them. Some mental health professionals are suggesting that we need to shift from trying to identify ‘what is wrong with you’ to finding out ‘what happened to you’, allowing people to tell their own story in their own terms, and work with professionals to co-create a way out of the distress they feel. To make that possible people need a sense of community, fellowship and support.
The open dialogue model pioneered in Lapland in Finland is now being used in a handful of NHS trusts in the UK and has had remarkable results. Open Dialogue centres and centres like the Bristol Sanctuary or Leeds survivor-led crisis service offer compassionate models of support; recognising that the process of recovery is one of emerging through difficulties with a different way of being, with the help and support of others. New thinking in mental health offers ways to rethink how we are as a society, identifying high levels of distress are a warning sign that our society has got it wrong and it will take profound change to regain a healthy equilibrium.52
The important learning from these initiatives is that they can’t easily be transplanted – they depend on the energy and leadership of key individuals - and the building of a community. They can’t be commissioned or planned in the old-fashioned top-down way, but they can be allowed to seed and to spread. As Simon Duffy says “Peer support is not a fixed model. There is no job description for being a peer supporter. You can’t buy it and you can’t sell it. But what you can do is celebrate it, protect it and nurture it.”54
Brilliant as these examples are, we need national government to create the right framework in practical terms.
In the first place, we all need to be able to adapt our lives to enable us to care for others. Instead of only valuing work, we need to value the caring responsibilities we have for children, parents, friends and neighbours. Historically undervalued as ‘women’s work’, though lip service is paid to its importance, we still don’t value it enough. Proposals to reduce the working week, and to make it easier to work flexibly, exploration of a universal basic income as Labour are doing in Wales and schemes to allow volunteering as part of our employed work all contribute to the rebalancing of our lives and making space for care.55
A future government needs to recognise the power of our highly hierarchical services to reimpose old ways of doing things. Constant reorganisation from the top makes this worse, as does a blame game. Top-down directives kill off innovation on the ground. Giving more power and autonomy to localities and neighbourhoods would create the vital space needed for experiment and learning.
Professional care workers need more than to be applauded on our doorsteps. Of course they need good pay and conditions, but they also should be free to bring their full human intelligence to work with them and to connect their care to that of a wider community. Powerful studies such as those conducted by Madeline Bunting illustrate how frustrated professional staff feel when they listen to the problems their patients and clients experience and are powerless to take action.56 Worse, we heard about migrant nursing and care staff, who felt as if they are regarded simply as ‘inputs’ and numbers and considered disposable. We need to treat care workers the way we want them to treat people in their care.
It will be important not only to invest in the education and training of future staff, but to change the nature of that training, to equip them with the skills to listen to service users and value their contribution, to collaborate with other professionals, to innovate. Staff who have spent their lives doing things in a certain way will need space to explore and change.
Crucially a future government needs to reassert the values of public service, care and kindness and to draw on these in the way that it treats leaders, managers and staff in public services and the way that it enables them to run their organisations. Alongside experimentation will be the need for constant feedback loops, practice exchange and shared learning - using the techniques of humble government that we will explore in chapter 5.
In other public services an open, exploratory approach is demonstrating ways to connect together the energy and creativity of communities with the resources and skills of institutions such as local government. The thinking that is going into health and social care is also part of how other services are being re-imagined. Parks, leisure, town centres are all being rethought – and new power offers ways of sharing ideas and re-engaging people. Creative ideas are being researched and shared by organisations such as the Centre for Welfare Reform, Co-operative Councils, Nesta, RSA and many others. Nesta’s ‘rethinking parks project’ is full of ideas and examples about how to rethink the role of parks and open spaces in our lives.57 Services that have always been seen as separate are beginning to combine – so that parks are developing community greenhouses that grow food for foodbanks, teach children about gardening and help adults find ways to protect the environment. Air quality officials in local authorities are connecting with health campaigns.58 Lambeth Food heath co-op is gardening with patients to grow food that is sold in hospitals.59 Sports and leisure organisations are getting together with primary care and mental health organisations to improve well-being.60 Central London Bartlett School of Planning has been exploring radical ideas for planning.61 The National Housing Federation has run a process called Housing Futures bringing together housing associations across the country with experts and the public to brainstorm ideas to transform housing.62 Schools such as the New School in Croydon are being reimagined to equip children with the collaborative skills they will need to work together in the future, enabling children to work together for real to create solutions to their everyday problems.
Social networks offer scope for people to connect together and share ideas about how to change the place we live in. The power to connect through the internet and social media creates new spaces to organise, both to create alternative services and institutions, and to enable connections with broader circles. Mutual aid organisations that sprang up at the start of the pandemic are examples of how technology can link together people in a street or a neighbourhood in ways that never happened before – and many of these groups are continuing once the immediate demands on them during lockdown reduce. People with specific needs or problems learn how to organise, with a view to improving how they are treated by public services, coming together to share what they know and help each other.
Innovative consultation processes can engage communities in reimagining their cities and towns. Some local authorities have linked with local universities, businesses, police, health and other service providers to explore ways to change the lives and livelihoods of their residents for the better.
