I followed Shadow Care Minister Liz Kendall MP in responding to ippr’s new report on The Relational State view of public service reform last night (video). The paper argues that public services which are organised either as big bureaucracies, or by free markets, can sometimes tackle simple challenges, but not the complex challenges faced by many people with long term conditions or who face multiple disadvantages. It argues that we need services which are better connected to the people they support and with each other, and for systems which allow for deeper relationships between professionals and the people with whom they work.
After saying a little about Shared Lives and our members’ work, this is (roughly) what I said:
The relational state programme says we need to devolve power, connect services and deepen the relationships between those services and the people they serve. It suggests that institutions which operate at a local level are better placed to do that than national government.
I don’t disagree with any of that, but I do want to suggest that today’s messages of connect and deepen can be pushed even further.
To do that it’s worth taking a detour into the lessons we can learn from social care’s introduction of individual control over state resources, through personal budgets, which are sometimes taken as a cash Direct Payment which the individual spends on the support solution, in theory, of their choice.
For a relatively small group of people who have used a Direct Payment to exert complete control over their personal support, this has been life changing. People have become employers of their own support staff and others have spent their money on things as far away from traditional services as leisure club membership or, like one small group of people with learning disabilities, creating a dance activities business. Those aren’t innovations you could commission for. They are often uncategorisable in service language, but they are a route to a very familiar set of goals which are shared by most of us: friendship, belonging, the chance to contribute.
On the other hand, many people who have wanted or needed the state to continue to spend their personal budget on their behalf have found less has changed. Much of that money has been spent on the same old services doing the same old things. Meanwhile, budgets and some whole services have been cut, often in the name of personalisation and independent living. Ironically, some on the left now blame the individualism of personal budgets for the fragmentation of services, when in reality the problem has been the lack of individualism: the state, with its standardising tendencies and innate mistrust of individuals, has stepped in to organise, mixing up a turgid brew of quasi-free market and old fashioned bureaucracy, squashing creativity and prioritising managing its risks above those faced by its citizens.
In contrast, the people with the most freedom, the Direct Payment holders, have often chosen to act not selfishly, but collectively. Their goals have been individual, but, without the state needing to act as a ‘standardiser’, that individual conception of a good life looks fairly similar: it’s been about forming friendships, finding somewhere to belong, feeling useful to others.
Many on the left continue to believe that giving individuals control over state resources must always lead to consumerism and competition for scarce resources. As a result, the left is typically willing to devolve power, but only so far. To get down below the level of local government is to increase the risk of leaving people isolated and vulnerable to the power of market forces.
The personalisation reforms of social care however, imperfect and widely mangled as they have been, have given us a glimpse of people’s ability and desire to act collectively, and of their power to change not just services but also their communities. The state has a vital role: not to organise or standardise but to enable people to self-organise. For the support of the most isolated and vulnerable, the state’s role may need to be more structured. You can see that in Shared Lives, where the local scheme, the council and the regulator work together to create just the right amount of space in which Shared Lives carers and the people whom they welcome into their homes can build whatever family life feels like to them. But the assumption must be that everyone has a shared responsibility for their own lives and for the outcomes of public service interventions into their lives.
So, yes connect and deepen, but the challenge is not to connect services with each other, but to connect services with the rest of people’s support eco-systems. Connecting services as they stand may only consolidate their deficit-based world view, in which people are services’ recipients not their workers, planners or owners. A personal resource allocation based on a view of me as a bundle of needs, will fail to help me build my strengths and will ignore my most important relationships. But the opportunity to control state resources, if coupled with support to connect to others with similar goals and needs, can change an individual’s status from recipient, not to consumer but to commissioner.
This is the ‘deepening’ of relationships which I believe will bring real change. Not just professionals forming a more complex picture of a person’s needs, but recognising that person’s ability to share responsibility and ownership of support solutions. This may be most obvious where a Direct Payment holder can control entirely their personal support system, but the principle of co-ownership needs also to extend to people using smaller or more episodic allocations of state resources to buy support. We know ways to achieve this. They include operating at the micro level, through helping people to form small groups to deploy their pooled resources on micro-enterprises, which thrive not in the free market, but in local marketplaces. And they include the co-operative, strangely scarce in health and social care provision, and almost entirely absent if you look for co-ops whose ownership is shared between workers and people who use the service.
So to finish, I welcome the shift down in scale and the idea of deeper connections. But let’s have enough trust in people to shift down further, to the micro-scale and to further deepen people’s connections with the services they use, through ending the private/public debate and instead making the user and worker owned co-operative the default governance model for service providers. If we started using them together, we’d find most of the tools needed to achieve this are already there: personal budgets, the community right to challenge, NHS workers’ right to request, the Social Value Act.
This isn’t about turning people into isolated consumers left to the vagaries of the free market, it’s a big ambition for large numbers of people to be supported to form small groups in small places, because that’s where good things happen and incidentally, where Eleanor Roosevelt said human rights begin*.
I owe that reference to the wonderful Small Places blog – see blogroll link opposite.