Monthly Archives: June 2013

How do Governments decide who is ‘deserving’ or ‘undeserving’ of support?

Governments ideas on how the relationship between state and society should be structured relies on what they think motivates us as individuals, this in turn will inform government on how to shape the public sector and welfare system. Many of governments ideas on the role of the state in society are reminiscent of past philosophers ideas.

For example ‘Big Society’ is influenced by the ideas of Edmund Burke, whose Reflections on the Revolution in France (1790) is widely seen as providing the philosophical foundations of ‘Big Society’. Burke was a supporter of localism and believed government should allow local discretion and respect for local customs to ensure social change was not the result of top down policies, suggesting if given space society was able to come together to resolve social problems, thus leading to ‘small government’. This belief is arguably shaping governments perceptions of the role of big society in supporting those in need and the governments drive to reduce the public sector.

Philosophy can also be seen in governments’ reform of welfare provision, especially views on who are ‘deserving’ and ‘underserving’ in society. I wonder if Ian Duncan Smith is a fan of John Locke (1632-1704). Locke’s views on poor relief could be government policy. In a memorandum to the Board of Trade, written in 1697, he talks about the rising number of poor and the unacceptable cost of poor relief, suggesting the rise was not due to adverse structural factors but was the result of the characteristics of the poor and failings in their behavior. It’s worth repeating his quote, it could almost appear as an editorial piece in some of our daily papers today

‘If the causes of this evil be looked into, it will be found to have proceeded neither from the scarcity of provisions, nor from want of employment for the poor. The growth of the poor must therefore have some other cause; and it can be nothing else but the relaxation of discipline, and corruption of manners: virtue and industry being as constant companions on the one side as vice and idleness on the other’ (Locke, 1697).

For Locke, since poverty, and reliance on welfare, stemmed from the personal failings of the individual it is obvious to correct the situation the focus needed to be on ‘correcting’ that individual (this was to be achieved via a harsh system of poor relief). Locke did recognize there were different levels of deserving and undeserving, and introduced a third category ‘the semi-deserving’, which broadly equates to those with disabilities today, but he did not write much about what needed to be done to them!

There are many other philosophers whose ideas underpin various political perspectives on the role of the state and society in the provision of welfare, but only one well-known female philosopher, who offers an alternative approach.

Mary Wollstonecrafts’ (1759-1797) writings on poverty are not huge, but very different in tone from her predecessors. Where others such as John Locke and Thomas Hobbes (1588-1679) saw poverty as the result of individual failure, Wollstonecraft recognized poverty in structural terms, partly as a result of the economic system and discrimination. Whilst others suggested reduction in poor relief would motivate the poor to help themselves, Wollstonecraft suggested people should ‘not be obliged to weigh the consequences of every farthing they spend, they should have sufficient to prevent their attending to a frigid system of economy which narrows both heart and mind’ (1792). Hmmm….

Whilst Wollstonecraft has not received as much attention as other thinkers, her views appeal to me because they were driven by a moral belief which put an ethical approach to care first.

What underpins your thoughts about the role of big society and the state in supporting those in need?

If you would like to read more on the philosophies underpinning approaches to welfare and the role of the state in society see ‘Major Thinkers in Welfare’ by Vic George, it’s a good read.

#Elderly care condition critical: we need ‘active’ leadership to create a care system that is both ethical and sustainable…..

As the BBC (Panorama, 17th June 2013) and CQC yet again bring to government and wider societies attention the poor levels of care some older people experience, one wonders will any government ever get to grips with this issue?

Whilst there are calls from government for families to step up and support older people, government seems totally unaware that the majority of families already do, and it is as a last resort that families call on public and private sector providers. However, far too many of these providers are simply not good enough, and for this, government has to accept some responsibility.

The transformation of ‘care’ into a commodity that can be bought and sold, like any other product, dominates current health and social care reform, however, discussion on what ethical principles might underpin the delivery of care has not emerged.

This raises the question is it wise to build a system of care provision with no clear ethical foundation?

We need greater ambition in developing great care for older people and a more strategic approach to make real improvements.

Developing ethically sustainable care for older people

Drawing on the ecology movement sustainable development is defined as “development that meets the needs of current generations without compromising the ability of future generations to meet their needs”. This captures two relevant issues; the need to support those older people currently requiring care, without compromising the future of the care system.

Need, capabilities and the ‘good life’

A first step in developing ethically sustainable care involves reframing our understanding of ‘need’.

Need in a health and social care context is often used to refer to a function to be fulfilled, i.e. nutrition, physical care. Such needs are viewed as a necessary condition for survival. However, we should also view older peoples’ needs in terms of security, respect, love and justice. The failure to distinguish between different types of need has led to limiting our understanding of how to care for older people, and has subsequently influenced how service provision has developed. Amartya Sens’ concept of ‘capabilities’ provides an alternative approach

Sen is concerned in this model with identifying what individuals require to flourish and live a ‘good life’. In this model it is recognised older people require different capabilities to flourish, depending on their personal circumstances and the community they live in, whether that community is within an in-patient/residential setting or in the wider community.

Successive governments’ appear to believe an expansion in a consumer culture within health and social care provision is the only route to a ‘good life’ for older people, as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care. Yet many older people are clearly not flourishing in a culture that defines the good life in terms of their ability to engage as a ‘customer of care’.

A more useful way of thinking about this, from an ethical perspective, links Sen’s idea of capabilities and Aristotle’s vision of the ‘good life’. From this perspective achieving quality of life is central, rather than just meeting physical needs. In other words it is not just about achieving an ‘average’ notion of well-being but about the opportunities available to the individual which will enable them to develop their full potential, whatever that might mean for that individual. This approach moves beyond ensuring older people have the ability to flourish to consider whether they are actually flourishing. Commentators suggest there are five areas in which older people need to flourish to live a good life, regardless of where they live. These are: belonging to a family; belonging to a community; having access to material goods for sustenance, adornment and play; living in a healthy environment; and having a spiritual dimension to life. Arguably the commissioning and delivery of service provision based on achieving these five areas might enable older people to receive care that is both compassionate and dignified.

The way forward

Conceptions of what constitutes a good life are varied, however, within health and social care provision it is prudent to assume a good life involves at a minimum care provision that is not abusive to older people. Within the public sector the organisation and delivery of care is structured to focus on the meeting of targets rather than enabling the individual to flourish. The NHS is arguably over managed and under led, with the aim seemingly to move older people into residential care as quickly as possible to free up beds. In the private sector it could be argued a free market economy contains structural incentives for business to pursue a notion of the good life that supports the sale of a narrow range of care ‘products’, whilst there are not mechanisms in place to ensure the market operates within a clear ethical framework outside of the profit ethos. By not actively regulating care provision from an ethical stand point government may actually be unwittingly aiding the abuse of the most vulnerable within the care system.

A shift in focus from human need to human flourishing has already begun with the development of the personalisation agenda and emphasis on voice, choice and control however, this agenda has been overshadowed by a managerial approach to consumerism and consumption in a low paid, low status care system and this is undermining the ability of the care system to develop ethically.

Michael Sandel argues markets are not a mere mechanism designed to deliver goods, they also embody certain values, and the problem is these values ‘crowd’ out non market values like compassion and dignified care. Where values and ethics are weak we need a strong and active state to intervene, where both are weak those most vulnerable in society will continue to be exploited and abused.

This begs the question can we afford not to have an ethical care system? I guess those older people who have already suffered abuse would say we cannot.

To see a wrong and not expose it, is to become a silent partner in its continuance (John Raymond Baker)

‘Old age,more feared than death’: have we ever care about older people?

Has there ever  been a ‘golden age’ where older people were consistently valued, respected and protected by family and the institutions that make up wider society?

The World Health Organisation (WHO) suggests the abuse of older people occurs in many parts of the world with little recognition or response. This serious social problem is often downplayed or hidden from the public view,  and considered mostly a private matter. Even today, the abuse of older people continues to be a taboo, mostly underestimated and ignored by societies across the world. However, evidence is accumulating to indicate that the abuse  of older people is an important public health and societal problem.

As such, it demands an active response, one which focuses on protecting the rights of older persons, starting with  a change in our perspective on whom, and what, we value in society.

Although representations of old age and societal responses to older people have differed over time it could be argued old age is more often viewed as negative.

In ancient Greece old age was portrayed as sad, with the Greeks love of beauty marginalising the old. Although some commentators suggest the reality was more complex with the portrayal of older people in the classics as ‘both pejorative and complimentary’ (Thane). For Plato reverence toward old people was a guarantee of social and political stability, whereas Aristotle disagreed with such positive images. Cicero’s work De Senectute, written in 44 BC, points to the variety in individual experiences of ageing, acknowledging that for those who are poor and without mental capacity ageing is miserable, however, suggesting older people need to strive throughout their life to remain intellectually and physically able.

Arguably this belief still underpins social care legislation and policy today in respect of older people.

It has been suggested older people’s status in society is linked to their ability to participate in society from an economic perspective, especially in terms of activity in paid employment. Historically where older people have been unable to participate in paid employment, help and support has been provided through a mixture of family and state support, with an emphasis by government on the former rather than the latter. However, commentators suggest post industrial revolution another victim of change were the elderly. The old did not merely lose power, they also lost respect. The rise of the alms-houses, and institutionalised poor-relief, suggests that their children were increasingly shedding responsibility for their support and transferring it to the community..

Although Thane  argues, this may have been due to families own depths of poverty, rather than lack of care or a shedding of responsibility. The abuse of older people was not something government identified as a problem throughout this period, although, self-neglect was identified as an issue which government sought to address in the 1948 National Assistance Act.

This is not to say it did not occur, for example, the 1942 Exceptional Needs Enquiry found most older people living with families were there under sufferance. They were often less well off than those who lived with strangers, and lacked essential items of clothing, bedding or household equipment as families used any provision, such as clothing coupons, for personal use. Whether this constituted abuse is not clear as many families who cared for older relatives were often living in poverty themselves and older people often willingly gave their families any support they could, even if this meant going without themselves. Of course, records do not exist to either confirm or deny whether such relationships were abusive or mutually supportive, however, it might suggest in terms of individual worth and personal identity, a cultural norm existed where the welfare of the younger generation was prioritised over that of the old by both young and old.

However, Peter Townsend’s landmark study of long-stay institutional care for older people in 1950’s Britain, provides a little more insight into the experiences of older people receiving care. One of the interviews he recorded was with a matron of a small private residential home in Greater London, which Townsend suggested was by far the worst home he had visited, whilst his commentary did not discuss the issues raised in terms of ‘abuse’, if, as a researcher today, I were to hear such an account I would make a referral to the local authority and the regulatory body for residential care, the Care Quality Commission, as the interview is clearly describing ‘abuse’ as defined in policy today.

This suggests the abuse of older people has been going on for a long time, but has been hidden from public view, but we do know now don’t we.