A fantastic blog by our senior Lecturer Di Galpin for LSE Policy and Politics Blog a recommended read!!!
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!
At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people?
The Royal College of Nursing’s research into the provision of care to older people suggested staffing issues were central to good nursing care, government have responded to this by suggesting we need to take a ‘trip advisor’ approach to raising the quality of services (photos optional presumably!). However, this is only part of the answer, problems extend beyond staff to patient ratios and will require more than patient recommends to improve quality. Working practices imported from the business sector into care provision, along with a poor attitude from wider society and government toward the care of older people in the UK also need to be addressed.
Abraham (DoH, 2011) suggested the mistreatment of older people in the NHS is not just about people being too busy, but also about staff being indifferent to older people, i.e. showing no particular interest or concern about older people. Coming from a professional background, where I have worked with nurses in hospital settings and as an academic teaching student nurses, it is fair to say I have never met a nurse who has purposely set out on their career to mistreat an older person. On the contrary, they have entered the profession because they want to care for people. So what changes once on the hospital ward?
Arguably, such indifference radiates from wider society onto the hospital ward. Both Government and society are disrespectful of older people, describing older people as a ‘demographic time bomb’, their care portrayed as an expense we can ill afford. Once such an attitude is prevalent in mainstream society is it any wonder a culture of disrespect flourishes across society, leading to the de-humanisation of the older person, wherever they might be. As Jo Webber of the NHS Confederation rightly point out; once in a hospital bed the older person no longer matters – achieving the task at hand efficiently is more important than the individuals’ dignity. This then provides the foundations from which poor practice in the care of older people develops across a multitude of care providers from public sector institutions to private sector providers through to the individuals that make up society.
Whilst external factors have an important role in shaping attitudes toward older people, this alone does not fully explain professionals’ indifference to older people when providing care. Understanding what happens between individuals embarking on nurse training to actually working with older people on a ward is also significant. Menzies Lyth’s research provides an interesting insight from which to understand what happens once on the ward. Menzies Lyth drew on Jaques (1955) notion of ‘social defences’ used by nursing staff to manage the anxieties inherent within their practice to understand behaviour within organisations.
Jaques (1955) initially used social defences to understand how nurses cope with the high levels of stress and anxiety associated with the job. However, it was developed later to take into account structural factors arguing that social defences were the result of poor organisational structure. This provides a useful framework from which to explore how current structural systems interweave to produce an environment where mistreatment flourishes on hospital wards.
Social defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses; one person performs the same task to many patients rather than working with one patient to provide all their care. This facilitates a distancing between the patient and nurse, which protects the nurse emotionally. Organisational factors support a depersonalised approach by moving nurses around wards, which then allows the nurse to distance themselves from patients so as not to become emotionally involved. Other social defences include a denial of feelings and over emphasis on professional detachment and strategies to reduce anxiety around decision-making, for example working in prescriptive ways, performing repetitive tasks, and delegating decision-making. The lack of connection between patient and nurse arguably facilitates an environment in which mistreatment might develop, or is ignored. Therefore, the organisation and delivery of care at a structural level within the NHS is of relevance to improving care for older people. Higher staff ratios would be a good start because we have to ask is it possible, emotionally, for an individual to deliver high quality care with compassion and dignity consistently in the current system?
Poor levels of care appear endemic within the current system, the speed with which each new revelation now appears is in danger of convincing government and society such an approach is the ‘norm’, however, we must be careful not to just accept this as inevitable, or somehow acceptable in a time of austerity. Indifference toward the care of older people represents the tangible outworking of a system of care that has lost its way; where commissioning outweighs compassion and meeting the demands of the system outweigh delivering care with dignity.
At what point does the government stop relying on gimmicks, voluntary codes and recommendations from those without any power to implement change and actually take a lead to improve nursing care for older people?
Improving care provision for older people is not just about today’s older population, it is about all our futures, our own and our children’s.
Securing dignity in care for older people is something society should strive for, however, change in the longer term requires more than a reorganisation of structures. Fundamental to change is how the care of older people is conceptualised in the UK.
The Commission on Dignity in Care for Older People has identified many significant issues, which if addressed could make positive changes to the future of care for older people. Whilst such changes could make a difference, lasting change arguably requires new thinking at a philosophical and ideological level at all levels of society.
Ideologically government needs to shift its continued emphasis on a consumerist model of health and social care provision. Whilst a consumerist approach is clearly of benefit to market providers, and the public purse, it is questionable whether such an approach is of benefit to older people. Many of the problems experienced in private sector care provision originates from the under regulation of the care market, which, whilst enabling providers to cut cost and make profit, does nothing to address the poor quality of care many older people receive.
Models of management imported into health and social care from the business sector to support a consumerist approach exacerbate the problem.
Organisational structures support a depersonalised approach, for example working practice which allows carers to distance themselves from the older person, so as to reduce any emotional involvement between carer and cared for. The breaking down of care into component parts, such as 15 minute visits, whilst, considered efficient from a resourcing perspective does not facilitate the building of a relationship between older person and carer. Surely, care is more than a timed task to be done to another?
Managerialistic approaches taken from the business sector influence not just health and social care professionals, but also wider society. Leading society to focus on the ‘management’ of older peoples care needs, such an approach serves to separate us all from the lived experience of the older person, care then becomes a transaction, intervention, a process, or target, by which governmental and wider societies’ need to reduce public expenditure is met, is cost really all that matters today?
Have we reached the position predicted by Zymunt Bauman (2008) who, when considering if ethics has a chance in a world of consumers, suggests designing, elaborating, and putting into operation values of mutual hospitality must at some point become a necessity for the human species? Bauman argues no place on the planet is spared a point blank confrontation with the challenge, because as Levinas (1961) suggests, the moral impulse to care for one another is a poor guide for behaviour when one moves beyond a one to one relationship to plural others (the Third) because it cannot be sustained. Something more is required, and that something requires substance.
A change in the philosophical foundations shaping our understanding of older people and their care should be the starting point.
German philosopher Immanuel Kant’s (1724 – 1804) ‘Categorical Imperative’ suggests everything in life has either a price or a dignity. A need for example for material resources has a price because it is replaceable, but that which is irreplaceable has a dignity. Morality, Kant suggests is one such dignity that cannot have a price. Arguably, compassion toward the most vulnerable in society is one such dignity that does not have a price, and is therefore above monetary value.
Dignity should not be viewed as an optional extra, dignity is integral to the care of older people across society. In the longer term for structural change to be effective a deeper and more meaningful approach to care is required because if we continue on the current pathway, as the Manic Street Preachers might suggest “if you tolerate this then your children will be next”.
The mistreatment of older people extends well beyond the confines of the hospital ward when we consider research suggests up to 500,000 older people are abused or neglected in the community each year (Action onElder Abuse, 2007) and older people routinely receive inhumane and degrading treatment in residential care (Joint Committee on Human Rights, 2007).
Six years on from both these reports not much seems to have changed, even though cries of indignation from both government and society continue, so does the abuse.
Any attempts to raise awareness and improve care provision for older people is to be welcomed, however, the introduction of voluntary dignity codes and trip advisor type systems alone is not enough to address an issue that goes to the very heart of society; our indifference to older people. The Health Service Ombudsman (Abraham, 2011) highlights the culture of indifference that exists in the health sector citing incidences of older people leaving hospital with numerous physical injuries, mentally confused and soaked in urine, whilst research suggests older people living in the community dominate the abuse landscape, yet are invisible to wider society (Mansell et al,2009). The conviction of carers charged with abusing older residents with demnetia at Hillcroft Nursing Home confirms how little has changed.
The level of our indifference can be measured by the difference in response following the case of ‘Baby P’.
The tragic case of ‘Baby P’ not only provoked outrage, but a commitment from government to change the system, with ProfessorEileen Munro outlining how structural and organisational change was required to improve services for vulnerable children. Surely, it is time to undertake such a review in the provision of health and social care for older people?
We need to start from a very basic level before we reach the same level of response as that seen in childcare. The prevention of mistreatment of older people requires firstly a change in society’s attitude. A dignity code may help, eventually, but hard legislation would work faster and send a message that the mistreatment of older people will not be tolerated. Legislation relating to the mistreatment of children demonstrates the value of specific legislation. Whilst child abuse has not been eradicated legislation has changed society’s response to child abuse i.e. there is a broad consensus that it is not acceptable. Other examples of where legislation can moderate attitudes and behaviour to vulnerable groups can be seen in legislation related to racism and homophobia, whilst, again, it is acknowledged racism and homophobia have not been eradicated, it has arguably changed wider society’s response to groups who have been traditionally vulnerable to abuse in British society.
Munro’s review has highlighted significant flaws in the organisational structures and practices that exist in childrens’ services, many within adult services would suggest those same flaws also exist within the provision of health and social care to older people. This involves not just looking at individual workers but also the organisational culture they work in, what use is it having someone sign a dignity code if the processes and procedures within the organisation they work prevent them adhering to them?
Our current system of care provision leaves many older people vulnerable to mistreatment, this has to change, a voluntary code could help, but on its own it will do nothing to soften the hardened heart of government and society who express outrage but just as soon forget the plight of many older people.