Public service reform, the individual and the state: our approach to public services needs to be turned upside down, with the focus switching to relationships and networks.
The aim of our work was to ensure a rich third age, one that every citizen might live regardless of income level or assets: a life less ordinary. In Southwark, our specific goal was the design of a new universal service that might be replicated nationally - supporting older people to live in a way of their choosing as they age. In Westminster our work has been more closely focused; we have worked only with those who define themselves as lonely, the majority of whom are over eighty and housebound, with the goal of facilitating rich social lives.
This article briefly tells the story of this work, the affordable solutions we have designed, and the nascent lessons for how we might re-think a welfare state, particularly its relationship to individuals and - most importantly of all - to wider social bonds.
In Soundings 35, Zygmunt Bauman argued that a self-assertive left should measure its activities against the experience of its weakest members. (2) Those who are older, in particular the 'oldest old' and the frail, provide a good benchmark for this aspiration.
Today one in five older people are below the poverty line, and one in three report themselves as lonely. The challenge is not new. In 1948 this same figure of one in three older people reported themselves to be lonely - a matter of deep concern to William Beveridge, who felt that the failings of the post-war welfare reforms he had orchestrated were already painfully visible in such statistics.
Loneliness, however, maps uneasily onto economic deprivation, and it is not usually a central concern for public service reform. It raises questions about the role of relationships: within communities, and between individuals, the state and the market. The service-delivery mindset, which underpins so much thinking about public services, finds it hard to think about relationships between people, as opposed to targeting a 'user'. This is a deep challenge for social reform, exposing the limits of the current welfare state, and of many of the reform models on offer.
Britain is ageing. The resulting burden on pensions, health services and social care services is acute. The funding gap in social care is predicted to grow by [pounds sterling]6 billion in the next twenty years if current eligibility criteria are maintained. Recent financial turmoil only exacerbates this gap.
In a Guardian article in 2007, hair-raising headlines accompanied a colour-coded map showing the levels of care available to people locally (Guardian, 22.11.07). Over three quarters of local councils have already reduced their help for the elderly to the point that only those with most desperate need are now eligible. As costs grow because of rising numbers, the article explained, councils will draw ever tighter guidelines around who is eligible for state support, in an effort to reduce budgets that are already spiralling out of control.
This is a narrative welcomed by the government, who believe that much work still needs to be done to 'educate' the public as to the extent of the crisis, in order that there can be a wide ranging debate and a new settlement around provision for the elderly, in a society where in the not-too-distant future three quarters of the population will be over the age of 60, and for every working person there will be two in need of support.
Seen through the lens of the state the problem looks intractable. Faced with numerical pressures there appear to be only two options. Raise taxes to pay for additional care or tighten the criteria to reduce the numbers of those eligible for care. Since it is widely believed that the general public will not tolerate increased taxes to support elder care, local government has chosen to tighten the eligibility criteria. This is in spite of the evidence that authorities that have already tightened their eligibility criteria have found it hard to make significant savings, since individuals once classified as 'moderate' usually deteriorate without support, until they are soon classified once more as needing state support.
This, then, is the widely accepted and dominant narrative on ageing in Britain. It is a story of a demographic time bomb, a story of the state failing numerous individuals. If we invert the telescope, however, and look from the perspective of individuals themselves, a very different story emerges.
In Britain, people over sixty hold 80 per cent of the nation's wealth-valued at [pounds sterling]1.3 trillion worth of assets at the start of 2008. Although the financial crisis has subsequently diminished this total, the share of national wealth remains the same amongst this population group - however unevenly distributed. Perhaps even more importantly, this expanding proportion of the nation's population make enormous social contributions (an estimated [pounds sterling]24 billion in unpaid work), and are a rich pool of talent, human resource and often - that most scarce of commodities - time.
One thing is clear: older people have assets which dwarf those of the state. Supporting an ageing society thus needs to start with older people, and to think differently about their relationship to the state, each other and the wider community of which they are an all too often invisible part. This has been the premise of Participle's recent work, and our starting point has been to work with older people themselves.
Through working closely with older people we have observed a number of deeper issues of dependency and inequality that are not tackled by current provision-even before cuts are made.
On the walls of our small studio in South London we have portraits of some of the participants in our project, revealing the rich variety of their lives and experience. Shirley, 60, is seen dating internationally on Skype. Robert, 65, is photographed dancing with his small daughter: he became a first-time father in the same month he started to draw his pension. People are living longer and many are inventing new ways of doing it: taking advantage of technology, better health, rich social lives and the opportunity to travel.
Also on our walls is a picture of Steve, 55, who spends most of his days in the pub. He is bored and very overweight, and last month was diagnosed with diabetes and a series of other health problems. Steve's story, as he himself recognises, is different: it is a story of impending crisis, a story that personally mirrors that which is told nationally through statistics. For individuals such as Steve, the concept of a third age - that supposed golden period between retirement and a frail older age - is mythical. His path will be one of a shift from a lifetime on low-paid work, followed by incapacity benefit, into an immediate, long and painful decline. This will be costly for the state and painful for Steve.
Conversations also reveal disappointment with the quality of services offered. There is resentment at technocratic delivery: what is sought are relationships. From the perspective of the householder, the voluntary sector - whilst sometimes praised for individual services - is tarred with the same brush; too often it refers an individual to yet another service, rather than offering any real help, and it frequently shares very closely in the technocratic culture. As the voluntary sector has been increasingly locked into bidding for contracts from the local authority, the personal touch and creative elan that once characterised many organisations has tended to be lost.
In the same authorities there is a parallel story of wealth and assets - in time and talents as well as in finance and equity (largely wrapped up in housing). One of the things we have been told most loudly is how much people want to give and contribute. But most are locked out, occasionally consulted as 'users', but never conversed with as individuals and communities.
Most people's needs are small and episodic: someone to go up a ladder once in a while, advise on how to use a new bit of technology, go through financial statements once a quarter, or offer support with a new situation. If left undone, apparently small things build up, until the state needs to come in with a blanket and expensive response. Once state help is provided, people tend to hang on to it. A hoarding mentality is common: resources are known to be scarce, and hard to come by in the first place, so people hang on to things they don't need, just in case.
Those with the strongest social connections to friends, family and neighbours are able to meet most if not all of their smaller needs before they become insurmountable. The increasing importance of social connections was clear from the earliest stages of our work, as were the challenges that many face in maintaining or making these connections. Many years of caring for a partner leave great numbers isolated and needing to start again at the very moment (the death of a loved one) when they feel most frail and vulnerable. Older people we worked with, whether because of their age or the generation to which they belong, often valued a smaller number of deeper relationships, which left them more vulnerable to isolation as others died or moved away.
As resources have become ever more restricted, however, the state has emphasised the provision of personal care services over any activity that might form greater social connections, making individuals ever more dependent on the state. This is most clearly seen in the provision of day-care centres, to which individuals very often have to be bussed, at high cost. Whilst time spent in these largely desolate places might be important relief for carers, those who visit them are unlikely to make any bonds with people who might be able to help them outside the centre, or to strike up more regular friendships, given the distance that day-centres are from people's homes.
It is as if the state is investing in making itself not only the provider of solutions but the friend to the elderly. It is a story of relationships in the wrong place
Very early on we saw patterns amongst those we met. The state relies on four categories to segment need (based almost entirely on finance and physical ability), and spends up to 80 per cent of the resources available on sorting individuals into these categories. We saw that old people themselves see their lives in terms of interests, skills, openness to new things and relationships past or present. Patterns in terms of attitude and outlook - which most determined the quality of life an older person was living - were largely independent of wealth or income, and did not correlate with 'needs' as traditionally understood by the state. Most simply, we were able to think of the people we had come to know along two continuums. One of these plotted their agency - their willingness to try new things; the other plotted their interests. It was clear that we would need different starting points or conversations depending on where an individual might be along a continuum.
We also understood what would be the components of any new universal service: practical help, social connections and a purpose for the second half of life. We began to put together the elements of a new universal service and to try them out in practice: the elements that would become Southwark Circle. In Westminster we began to try out a new service to connect the lonely and the housebound, a service we have called Meet Up.
Southwark Circle is a membership organisation: a nominal monthly fee makes it open to all. Combining elements of a co-operative, a concierge service, a self-help group and a social club, the Circle changes the locus of decision-making, starting with its individual members and journeying with them, as their needs change. An expanded resource base is created through drawing on the skills of members, the voluntary contributions of neighbours, private money (from wealthier older people and their families) and state resources better deployed. Southwark Circle is a platform for new and existing services: a place that can draw together the best the state and the voluntary sector have to offer, combining them with new offers such as a film club, gardening and household services.
The Meet Up Service creates and supports resilient social networks. There are four elements to the service: introductions (taking into account location and the importance of the first hundred yards); phone groups (topics include music, films and current affairs); trips and transport (based on scooters and a taxi card scheme); and activities at home. The service has been designed specifically to overcome the barriers of decreased physical mobility, and early take-up of the service has been concentrated on the housebound and mobility impaired, although there is nothing to prevent those who are younger joining in. For Westminster Council this preventative service has proved attractive through its ability to reduce costs in other areas.
If the issues around an ageing society illustrate the biggest problems of the welfare state - the underlying inequalities, costs and dependencies, and the fissures that have developed between people - they also show the route to the fashioning of a very different model. We call the set of principles on which our new model depends Beveridge 4.0, in recognition of the fact that any new settlement must be as ambitious and bold as the original welfare settlement, but, equally importantly, that 'room, opportunity and encouragement' must be kept for voluntary action and the power of the citizen (as Beveridge acknowledged in his third and last report, towards the end of his life).
There are five key shifts which underpin Southwark Circle (and to a smaller extent Meet Up) - and potentially a future welfare state. They are as follows: a focus on building capabilities (as opposed to meeting needs); an emphasis on universal services; a definition of resources which goes beyond the current limited financial models; national platforms that support highly distributed, local responses; and an emphasis on social networks that understand the individual and their needs within a web of relationships.
Beveridge 1942 was a needs-based model. The focus was on the five giants of want, disease, ignorance, squalor and idleness. Clearly many of these giants, although differently labelled today, remain as significant as ever. More important than the definition of the giants, however, is the underlying philosophy of need. Our work inverts this model and focuses on assets. Specifically, the cultivation of three capabilities: learning and work; relationships; and the environment. (The capabilities approach, drawn from the work of Amartya Sen and Martha Nussbaum, has been used to underpin the Swedish welfare state.)
Older people have much to offer the labour market, and are often interested in teaching and learning. At the level of the household, this was what people wanted to discuss - the jobs they wanted to do, whether paid or voluntary, the courses they wanted to take, the skills they thought they could pass on to others. Southwark Circle will go some way to addressing this demand: members will volunteer and be paid for their work. The focus will be on supporting those who so desire to enter the labour market, against the grain of age prejudice. Making connections to platforms such as the School for Everything and Pune University will open up learning opportunities.
Ideally one imagines that relationships are something there might be time for in the third age. The story is more complex however. Geographical mobility means that many older people are living at considerable distance from their families. Our work built a strong picture of concerned adult children who would like to ensure different lives and provision for their parents as they become more frail, but are unsure where to turn. Stable communities of face-to-face relationships are also harder to find. Any response within the new social state needs to provide the tools for social participation - between older people, across generations and across spatial divides.
Southwark Circle places the need for relationships at the heart of its offer. This starts with those who work for the Circle, and a business model that prioritises face-to-face interactions and personal stability - seeing the same person again and again; and there is also a cost model that does not penalise a frontline worker for having a cup of tea and a chat. A relationship mindset also pervades every aspect of the offer - helping connect older people to their relatives in new ways; helping navigate feelings of insecurity around young people; developing involvement in neighbourhood schemes; or understanding what will keep a volunteer. Borrowing and adapting from different places - within Britain and globally - has been critical to the development of the service. The neighbourhood scheme draws on neighbourhood watch, and the inter-action skills offer draws on a Norwegian service offered to old people.
Environmental concerns of old people tend to focus on place and neighbourhood. A recurring theme in our work has been the need to make older people publicly visible, and the tangible ways in which broader issues of social participation and wellbeing are linked to the physical environment - for example the quality of the pavements, the availability of benches and toilets. Fear, particularly of the younger generation, is also a strong determinant of lives. Southwark Circle will call people when they return home, for example, because we have learnt that the fear of returning to an empty house will stop an older person doing something they would otherwise very much like to do.
A rich third age depends on being physically active, socially engaged and maintaining a range of interests. Thus the more heavily and widely members use Southwark Circle, the richer the lives of Southwark residents will be - and, from the perspective of the Council, fewer expensive curative-type services will need to be called on
If services are protective and preventative it follows that they must be open to all and aspirational - in the sense that everyone can and wants to join. Ageing is a good example of the need for such services, but similar motivational issues underpin effective preventative health work, future climate change solutions and many aspects of Participle's work with youth. The design of universal services in turn leads to a very different way of thinking about resources, and the economics of service provision.
A new contributory principle
Ageing is currently framed as a narrative about fiscal deficits, when it needs to be about social contribution. The current narrow financial focus, which links an individual's entitlement to benefits to a system that focuses on National Insurance contributions, extends into and limits the consideration of the nature of services required and how they might be paid for. In this context, individual budgets, whose 'uncertain' merits were discussed by Peter Beresford in Soundings 40, can be seen as still rooted in the old economy. They might bring benefit to some, but most will find they are not eligible, since budgets will be linked to a residual model.
Southwark Circle expands the definition of, and access to, the resources available. Our work in this area contributes to a number of similar innovations taking place internationally, from participative budgeting in Porto Alegre in Brazil to experiments with voluntary financial contributions in Bogota in Colombia. When considered together this work poses a bigger challenge to the framing of public service debates.
Distributed institutional networks
Our existing welfare state and public services operate on highly centralised principles. The current debate about devolving more power to local institutions, whilst welcomed, does not get to the heart of the matter, since it still perceives a world in which things are largely done to and for people and communities. The only difference is that now local, rather than national, government will be 'doing' it.
More bottom-up, participative approaches depend on, and are sustained by, a more distributed model. Ivan Illich described how 'good institutions encourage self-assembly, re-use and repair': 'They do not just serve people but create capabilities in them, and support initiative, rather than supplanting it'. Southwark Circle is at once hyper-local and national/international (combining street-level support with specialised or collective macro support), and works on just such a philosophy. The more it is used, the more sustainable it becomes, as expertise and resources are distributed amongst the members.
Such distributed solutions radically change the nature of the relationship between the individual and the state. At the local level, interaction is more 'human' and personal; collaboration is more feasible; and a genuine conversation around issues of priorities and contributions becomes possible, further reinforcing relationships. Finally, it is important to note that these distributed institutions will be infrastructure-light, in contrast to their 1950s predecessors-critical in a time of financial scarcity.
Our lives are greatly determined by social networks: those of us who have strong bonds with families and friends tend to live longer and happier lives. One of the most striking insights from our deep participative work with older people, their families and social networks has been the discovery of the extreme difficulty experienced by many adult children in ensuring that their ageing parents and neighbours have the provision they need. Most adult children live at a distance from their ageing parents, which makes caring for them even harder. Strikingly, even so-called 'self-funders' - those that do not need help from the state but are looking to buy help in the private care market - face the same issues.
People want to support each other but the systems and services on offer make this hard, if not impossible. Southwark Circle inverts the traditional hierarchy of needs. The current hierarchy helps people with their basic material needs, but sees their social life and social connections as 'nice to have', but not as an essential part of the picture. We have seen that using limited resources to enable a social life has the effect of expanding the resources available: the time and talent of friends, neighbours and family can more than meet the material needs. In other words, connecting people starts to re-configure the possibilities.
Participle's work starts with people and their communities, putting the individual rather than the state at the centre. Seen from this angle, it is the state that is lonely - at arms length from the communities it could serve, unable to tap the energy, skills and resources of individuals and often threatened by individuals' attempts to make meaningful social bonds with each other.
The current crisis is a moment of opportunity. We have been faced by two dominant, atomising narratives: the market telling us that we are individual consumers defined by our desires and wants, the state telling us that we are individuals defined by our needs. If there is one message that we have heard most loudly in our work it is this: even in the most 'difficult' of places and of life's stages, we want to be socially connected and to collectively contribute and make change happen. Above all we want not to be lonely and in this desire lies a set of principles to guide a very different model of public service reform.
(1.) For more information on Participle see www.participle.net.
(2.) Available online at www.lwbooks.co.uk/journals/articles/bauman07.html.
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|Date:||Jun 22, 2009|
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