‘What is the point of the Labour party when there is no money?’ ask the Purple Papers, whose focus is on smarter spending of public money alongside fairer taxation. Their suggestions on both are credible, but the Papers’ transactional view of government may thwart its radical intent.
Whilst the authors see the coalition’s faith in spending cuts as simplistic, both right and left share a tendency to think equally simplistically when it comes to creating wellbeing. Creating health, for instance, might appear to be about deciding where, how and on what to spend £100bn or so of taxes. But that is how to create ‘illness treatment’ services. Creating health or any other kind of wellbeing (such as safe communities) is not something achieved by the simple deployment of money, however cleverly buildings and personnel are managed. You do not need to be a ‘small state’ enthusiast to recognise that the creativity and capacity of individuals, families and communities ebbs and flows in a constant dance with the state’s deployment of services, buildings and systems.
The ‘big society’ attempted to articulate that relationship between state and community, but, coming from an ideological standpoint, it struggled to match its vision with ordinary people’s experiences. Many of us will have encountered red tape, but few have genuinely felt stymied in their creativity by a glut of services. Conversely, some on the left assume that the choice is between traditional services and abandonment. When services are not present, people will indeed start to do more for themselves and each other. Is there a way of harnessing that latent creativity without a sink-or-swim programme of cuts?
One change in the private sphere which both agree is inescapable is that an ‘explosion’ of older people will represent a mushrooming ‘burden’ upon ‘resources’, which must be paid for from tax, insurance or privately by those who can afford to. We certainly need an insurance scheme for the costs of care. But the care paid for by any scheme remains a fraction of the care provided to older people, more than 90 per cent of which (£100bn+ pa according to Carers UK) is provided, unpaid, by families. Those families are not, in my experience, asking the state to get out of their way, but they are asking the health and care services to work with them in a very different way. Older people would like to be safe and well-cared for, and to know that their dignity will be respected even as their care needs increase beyond their own or their families’ ability to meet them unaided. But older people feel they have much to contribute to those around them and report that remaining active is crucial to every other aspect of their wellbeing. Being an active citizen, feeling like you belong and avoiding loneliness are not forms of wellbeing which services can deliver, no matter what proportion of taxes we use or how we use them.
In a recession, those with a transactional view of government will dismiss such sentiments. ‘Community building’ and ‘prevention’ are complex, touchy-feely goals for better-funded, less urgent times. But this is a crisis, needing hard-nosed thinking and tough spending choices. This is wrongheaded: both left and right need to agree that the relationship between state and community is neither straightforwardly nurturing nor straightforwardly stifling. Between 1997 and 2008, spending on adult social care in England and Wales rose by half but report after report highlights failings in services, lack of choice and increasing isolation. Conversely, most of us can point to the small organisation which sustained a much larger support ecosystem, but which has folded for want of modest funding.
Patrick Diamond suggests there are ‘significant savings’ to be realised from the personalisation agenda, which he characterises in terms of the mechanisms of consumer choice (individuals able to spend their resource allocation with relative freedom, rather than accept an off-the-shelf service). This assertion is not referenced because, I suspect, there is as yet no clear evidence for it. Given a genuine choice of services, most people will choose a service which better meets their needs, not necessarily a cheaper one. That rise in service quality may keep the individual out of acute services – or may result in informal support networks withdrawing and increasing isolation.
In a time of financial austerity, we need to support care where it is still abundant – eg in the families of six million unpaid family carers – and where it could be abundant: among neighbours and wider communities. The last question Diamond asks, ‘What further scope is there for “co-production?”’, is the most important. Co-production is not, as Diamond suggests earlier in the Paper, a transaction in which citizens offer expertise in exchange for a greater say. It is recognising that a public good, like care or inclusion, is produced by citizens and communities, with organisations acting as their partners. How can we help families with an older and disabled member remain financially and emotionally sustainable? How can we help communities become inclusive? The answer to those questions may not be the local day centre.
We already know a little about how to provide support within the ecosystem of community. ‘Networked’ models of care and support recognise that ‘community’ is not a place (as assumed by ‘care in the community’) but a set of relations. Shared Lives, in which ordinary people are supported to share their homes and family lives with older people who visit them instead of visiting a day centre, or people with learning disabilities who move in rather than living in a care home, already reaches 15,000 people and is growing by up to 25 per cent a year in some areas. Care4Care is being piloted as a time-banking approach for people wanting to contribute care now and claim it back in later life. Diamond is right to say that ‘The funding of long-term care for the elderly is an unavoidable issue’ and the adoption of Dilnot along with his other suggestions are all entirely sensible solutions for bridging the financial gap. But whether those changes will make a jot of difference to the quality of older people’s lives will depend upon what kind of system is funded. And the relationships between state, families and citizens within that system must on no account look anything like they do at present.
—————————————————————————————
Alex Fox is CEO of Shared Lives Plus, a board member of the Think Local, Act Personal sector improvement partnership and chair of the Care Provider Alliance. His Personalisation: Lessons from Social Care is published by the Royal Society of Arts.
—————————————————————————————