Tag Archives: dignity code

It’s time to stop meeting needs and start focusing on developing a ‘good life’ for those who use health and social care services…..

The funding of the health and social care system is currently at the forefront of policy and is overshadowing any understanding of the values and ethics that should underpin care provision, to the extent a consumerist based system is viewed as superior simply because patients and service users become purchasers. However, evidence would seem to suggest this is not always the case. This raises the question for me is it possible to build a system of health and social care provision that is both affordable and based on values such as dignity and respect?

Developing a sustainable care system

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 important elements, the need to support those currently requiring care without compromising the future of the care system which is able to accommodate a growing number of users within budget constraints.

Need, capabilities and the ‘good life’

A first step might be to reframe our understanding of ‘need’. The concept of human need is a relatively new one, and is used in different ways. 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 might be viewed as a necessary condition for survival. However, we can also view need in terms of security, respect, love and justice.

The failure to expand our understanding of need has arguably led to limiting our vision of human needs, and subsequently influenced how service provision has developed across a number of patient/service user groups i.e. older people, learning disability. A more useful way of thinking about need, from a values perspective, is provided by Amartya Sen with his concept of ‘capabilities’. Sen is concerned with identifying what individuals require to flourish and live a ‘good life’. For Sen whilst some capabilities depend on the fundamental provision of the basic elements of life i.e. nutrition, warmth and shelter, others require particular kinds of freedoms and social relationships. In this model it is recognised different 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 lived in the wider community.

While the ‘good life’ is to some extent subjective it is also socially defined. In modern western societies it is largely defined in material terms as our ability to be consumers. A consumer culture within health and social care provision appears to be the route to a ‘good life’ as it enables individuals to increase choice and control by becoming consumers of care, rather than receivers of care. In this context care is viewed as a commodity, to be bought and sold. Thus enabling the individual to pursue their own version of the ‘good life’. Yet many people who use health and social care services are unable to flourish in a culture that defines the good life in terms of their ability to engage in a consumerist model of care.

A more useful way of thinking about this from an ethical perspective links Sen’s idea of capabilities back to Aristotle’s idea of the ‘good life’, where the good life was a life of happiness based on the exercise of rational capacity and moral virtue, but also requiring material means and relationships with family and friends. These were the essentials of a good life. Martha Nussbaum has expanded the specific capabilities drawing attention to the need for individuals to be free from state interference and free to form meaningful relationships with others to flourish. Nussbaum locates a capabilities approach around an individuals quality of life suggesting ‘it holds that the key question to ask is “what is each person able to do and to be?”. 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 develop their full potential, whatever that might mean for that individual.

This involves going beyond ensuring people have the ability to flourish to ensuring they are actually flourishing. This is pertinent to all service provision whether within the community or in-patient/residential setting.

Five areas important to flourishing and living a good life, regardless of the society/community you live in 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 commissioning and delivery of service provision based on supporting the development of these five areas might enable individuals in receipt of health and social care services to flourish and have if not a good life, a better life.

A 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 of those who are vulnerable. A first step might be to be more explicit in embedding the principles of capabilities and the good life to provide a solid foundation on which to build for the future.

‘Big Society’ and the future of health and social care

David Cameron suggests the Jubilee party was a ‘perfect example of ‘Big Society’.  Whilst it’s okay for a knees up, is it a suitable foundation for improving the quality of care  older people receive in Britain?

Unfortunately, David Cameron’s comments on Big Society do little to help us understand what “it” actually is, and to be honest, I am not even sure he  knows what it is beyond the usual sound bytes of ‘kitchen sink economic theory’*.  However, could the concept of Big Society actually have something to contribute to the debate on the future care of older people?

What is ‘Big Society’?

Big Society has been vilified as a return to the politics of the New Right,  a Trojan horse for smaller government,  and feted as the anatomy of the new politics  on which to establish the legitimate nature, and limits, of the relationship  between the  state and individual in a 21st century system of health and social care.  Phillip Blond is a central figure in the development of the concept of Big Society.  Blond  argues both the political Left and political Right have presided over a collapse of coherent cultural values and a shared commitment to a ‘common good’,  suggesting a redistribution of power from the ‘top’ (state) to the bottom (individual) is required, aligned with a more compassionate form of capitalism, to re-establish the common good.  For the current government this rests on the empowerment of local communities founded on voluntary networks of trust and mutuality.  From this perspective the purpose of Big Society appears to be to extend responsibility for the care of older people to local communities, rather than extending the responsibility of the state.

Policy programmes already implemented by the current government to develop Big Society include the National Citizen Service, which organise voluntary opportunities for young people, and the creation of the Big Society Bank, which will act as a central source of investment income for third sector organisations.  The Localism Bills’ accompanying guidance states ‘Big Society is what happens whenever people work together for the common good.  It is about achieving our collective goals in ways that are more diverse, more local and more personal (HM Government, 2010: p.2).

However, whilst at one level Big Society can be viewed as a mechanism of transferring more responsibility onto individuals, allowing the state to reduce public sector spending (Alcock, 2012) Big Society is also about believing in, and building on, the inherent ‘good’ within humankind.

Jesse Norman suggests Big Society involves moving beyond the ‘two way opposition of state vs. individual’ in the provision of care to ‘the three way relationship of enabling state, active individual and linking institution’ (2010,p.7).  For Norman the former is flawed because it ignores the diversity of human beings and their ability to act morally without interference from the state.  By justifying the legitimacy of the state, it polarises the individual and ignores the positive power and potential of individuals to create and maintain a ‘good society’, which cares for one another for altruistic reasons, rather than because the state legislate that society provide care and support.  Norman suggests state interference is a negative response to care provision, quoting Alex de Tocqueville (1805-1859)

“The more [the state] stands in the place of associations, the more will individuals, losing the notion of combining together, require its assistance.  These are cause and effect that unceasingly create each other.”

The ‘associations’ that mediate between individuals and the state can be conceptualised as operating within civil society.  Civil society is the space of un-coerced human action, the place where people take action as moral beings,  via all organisations and associations above the level of the family and below the level of the state.  The place where your jubilee street party was planned presumably.

Importantly for advocates of Big Society the role of government in this ‘space’ and ‘place’ is minimal.

How does this support the current approach to caring for older people?

From this perspective caring for older people, and ensuring care is dignified, is viewed as something we all agree is a ‘good thing’ and freely engage in, rather than something government should regulate or legislate for.  In this context government relies on ‘phillic’ associations, taken from the Greek ‘philia’, meaning friendship ties, affection or regard that are the essence of the space between individual and state.  Government would rather rely on these to guide human behaviour in the care sector than introducing legislation or regulation.

Hence, the governments  support for the introduction of a voluntary dignity code  (The Telegraph., 2012).

Big Society, freedom and money

However, whilst government may think treating older people with dignity and respect is viewed as a ‘given’, assuming we are all willing to  care for, and protect,  older people,  this is not necessarily true, as evidenced by a number of reports on the poor levels of care provision  older people experience across the care sector.

At the heart of the current debate are two related themes.  Firstly, an attempt to understand how the relationship between the state, private sector and individual should be formulated to fulfil a mutual responsibility in supporting dignified care for older people, and secondly  the affordability of care provision.   Successive governments since Margaret Thatcher have relied on a consumerist approach to improving the quality of health and social care provision. The question is has turning vulnerable older people into consumers improved their care?  For some yes, but for many of the most vulnerable older people in society, those older old people with dementia and who are frail, I’m not so sure.  However, what it has done is hide the abuse and mistreatment of older people from collective view for the last 30 years, and led society to engage in debate that does not move beyond the financial.  Research suggests this has had a detrimental effect on the moral health of society and academics are now suggesting the use of market mechanisms can change people’s attitudes and values, having a  ‘corrosive effect’.    Michael Sandel makes a pertinent point suggesting

It calls into question the use of market mechanisms and market reasoning in many aspects of social life, ……to motivate performance in education, health care, the work place, voluntary associations, civic life and other settings in which intrinsic motivations or moral commitments matter‘ (What money can’t buy, 2012, p122).

It is impossible to ignore the effects of systematic inequalities in liberal societies that effectively exclude, or compromise the rights of a variety of social groups.  Nor can we ignore the corrosive effect successive governments use of a consumerist approach to health and social care might have had on those ‘phillic‘ associations so vital to a ‘Big Society’.   The ‘Osborne Supremacy’  assumes the existence of a single unified ‘big society’ when it actually consists of many ‘societies’ with competing interests where the interests of powerful elites are advanced in the name of defending common interests, whilst the interests of marginalised groups, such as older people,  leave them without support.

Big Society or Big Con?

The answer will depend on your political and ideological viewpoint on the legitimate role, and limits, of the state in the provision of health and social care.  Whilst it is true Big Society clearly already exists, evidenced by the number of people already providing care freely in society, what is in doubt is whether it can be extended any further without an active state (Sullivan, 2012).

* Kitchen sink economic theory -this is a term used in my household to describe David Cameron and George Osbornes approach to the financial crisis.  It refers to a vision I have of a post war couple discussing there finances whilst stood washing up at the kitchen sink.  Gladys turns to husband Frank and says “money is tight Frank, what will we do?”  Frank turns to Gladys and answers “never fear mother, we’ll just have to tighten our belts, don’t worry we’re in this together”.  Of course Frank and Gladys are very naive and do not realise their actions will make no difference because the problem is a global financial crisis and not related to Gladys splashing out on a new apron!