Simon Duffy

Thoughts, Bemusements & Arguments

Tag: healthcare

Can Socialism Reinvent Itself for the 21st Century?

I am a proud member of the Socialist Health Association. I feel strongly that decent healthcare is a basic human right and that nobody should be deprived of it because of poverty, nor should the wealthy be able to buy their way to longer or healthier lives. If this is socialism then I’m a big fan.

Recently, the Socialist Health Association decided to review its fundamental principles, and as a philosopher by training, I thought I’d try and help clarify what socialism, at the beginning of the 21st Century, really means. However this turns out to be a rather difficult task.

It is certainly clear that socialists are against greed, exploitation, inequality, capitalism (possibly) and injustice (certainly). But what are socialists for?

One clue might be found in the social- part of the word socialism. Socialists believe in society, and more specifically I think socialists believe that society should come before the individual, that individualism puts the cart before the horse. 1 Certainly, the Socialist Health Association’s first principle as it currently stands, reflect this:

“The claims of the individual should be subordinate to social codes that have collective well-being for their aim, irrespective of the extent to which this frustrates individual greed.”

Now, as a piece of English, this is somewhat dry, abstract and rather confusing.

First, there is the strange notion of “claims”. This is quite a peculiar word. What am I claiming and to whom? Why is anyone interested in my claims anyway?

Second, there is the notion of sub-ordination. In what sense are my claims meant to be subordinate? Must my desires, plans or projects be directed towards “collective well-being”? This seems totalitarian in its ambition.

Or, on the other hand, are my claims legitimate as long as they don’t directly contradict the “social code” which has (somehow) been identified as for the greater good? Perhaps I can claim the right to drink alcohol, but I must only do so to the extent allowed by the state. This is perhaps nanny-state socialism, a little more tolerant than the totalitarian version.

All of this seems to be far too strong and quite alien to my reasons for supporting the NHS and social justice. I don’t want to be slotted (tightly or loosely) into some social code for collective well-being. I want to live in a decent society where we treat each other as equals. I don’t want to tell people how to live; I just don’t want to be advantaged at the expense of others, or to see others so advantaged. I really like the fact that the NHS is organised to limit how someone can jump the queue to get a better or faster treatment than someone else with similar needs, but less money. It’s fair.

The third problem with this way of defining socialism is that we are often confused about which “collective” matters. We can be part of many collectives: the family, the tribe, the class, the nation or humanity as a whole. Sadly, it has not been too hard for the wicked to corrupt the ‘social’ inside socialism into one ideal group that should be valued above all others. There is more than a theoretical link between socialism and national socialism and the twentieth century has seen millions sacrificed on the competing altars of these deathly versions of socialism.

But it is possible to imagine a better kind of socialism and one clue can be found if we go back, beyond the word society, to its Latin root socius or friend.

Friendship has nothing to do with state power and control. C S Lewis was not alone in observing that, at its core, the relationship of friend-to-friend is not a relationship of dependence, assistance or charitable action. Friends get along, even love each other, but not ‘in order’ that they can help each other. Helping gets in the way of friendship, and this is why friends hate to be in debt to each other. An undue level of do-goodery and interference in the lives of others is also irritating and unhelpful. It is certainly not friendly.

The challenge for socialism, at a practical level, is to convert our commitment to justice and our proper sense of responsibility for each other into a way of living that is ethical and sustainable. People who live only for others are not much better than people who live wholly for themselves. Citizens understand that they have obligations to themselves and to other people.

In practice most socialists are not trying to create totalitarian states or nanny states and they are quite aware that all human being are equally important. Today, much of the moral imperative of socialism has been converted into support for the welfare state and for the social contract it seems to imply: I must be prepared to pay my taxes, and in return – and as an equal member of society – I become entitled to some rights, such as being able to get free healthcare.

Now this welfare-state-socialism seems relatively benign, however it still has some peculiarities. For instance, notice that in this example of day-to-day socialism, the agent of good is now no longer acting from any moral principle. The doctor is not treating you because she’s a good person; instead she is (very) well paid to treat you. It is not the doctor who helps you, it is the anonymous welfare state, it is the system. So, interestingly, in order to operationalise itself socialism, appears to have moved away from the notion of friendship or mutuality. If we are not careful, the whole thing starts to feel entirely mechanical or transactional. I do this in order to get that. But then what is the difference between this kind of welfare-state-socialism and the kind of left-leaning liberalism that sees the welfare state as form of national insurance: we all put something in (according to our means) and we all get something out (according to our needs).

What seems to be missing is any deeper sense of our responsibility to our community, or even a sense of our unique individual value. Society has been converted from human-sized communities into a vast state-run charity. This may be a charity from which we all benefit, but as Arendt says, “charity is not solidarity.” In the face of this monolithic system we each become one part donor and one part recipient, one part tax payer, one part service user. The uniqueness and value of ourself and of our community disappears from view.

Welfare-state socialism is much better than totalitarian or many-state totalitarianism and much better than heartless forms of liberalism and individuals. But does it not feel we’ve sacrificed too much? Is there not a better way of defining socialism for the 21st century?

The fact that the meaning of socialism can be corrupted is no reason to abandon it, nor to abandon the concerns that it was developed to address. The underlying reasons for socialism are as real today as they were yesterday. Economic forces and greed do not control themselves; even the minimal democratic control of the state which we ‘enjoy’ today is no guarantee of justice, particularly when power and influence seems so easy to purchase. It remains essential that we examine what is really to the benefit of society, and not to treat society as if it were merely equivalent to a mass of self-interest.

However, if socialism is going to thrive we must find a better version of socialism.

For me the best starting point is the idea of citizenship. To be a citizen is to be much more than taxpayer, much more than a voter and much more than a right-holder or recipient. Citizens make community; their actions, innovations and creativity are the source of social value. They may be prepared, in extremis, to die for their community – but actually, more often, they get to live for their community.

The model of citizenship I use has seven elements, and I think each could be explored to develop a reinvigorated and healthier sense of what socialism might mean:

  1. Purpose – Citizens have a sense of purpose which is encouraged and supported; today’s dreams are tomorrow’s solutions.
  2. Freedom – Citizens are free, free to do their own thing, free to work with others, free to do the unexpected.
  3. Money – Citizens have enough, they abhor poverty and they don’t like excessive inequality (Plato’s suggested 1:5 income ratio for poor to rich would be much better than today’s tasteless and destructive excess.)
  4. Home – Citizens have homes, roots, neighbours and a sense of belonging. They are part of the community and they construct that community.
  5. Help – Citizens help each other, need each other, and know there is no shame in getting some assistance. However, what citizens don’t tolerate is sacrificing their freedom in order to get that assistance.
  6. Life – Citizens live life to the full, they work (and they know paid work is only one kind of work) they rest and they play. Citizens seek balance and know that you can only get out of life what you put into it.
  7. Love – Citizens need love, cherish love and respect love. Family, friendship and loving partnerships are all aspects of life that citizens nurture and protect.

Defining 21st Century Socialism seems a worthwhile project. The key I think is to leave behind the paternalism of the welfare-state-socialism and to rediscover the spirit of citizenship and community which actually built the welfare state in the first place. This does not mean abandoning the welfare state; it means reinvigorating and redesigning the welfare state. We must build the welfare state again, but this time not bury its builders and architects beneath its edifice.

  1. This point has a long pedigree; Aristotle, for instance offers us an early version of socialism “…even if the good of the community coincides with that of the individual, it is clearly a greater and more perfect thing to achieve and preserve that of a community; for while it is desirable to secure what is good in the case of an individual, to do so in the case of a people or a state is something finer and more sublime.” ↩︎

We’re Getting Older – Don’t Panic, Don’t Panic!!

Some days seem to have a curious symmetry to them, and this week I have had one of those days. It began in the heart of the Whitehall and it ended in a community radio station in East London; but the theme at the heart of the day was constant: what does it mean that we are now living longer?

The first discussion was a roundtable with some of the leading academics and experts in health and social care. (If you are wondering why I was there then you are not alone; I don’t know either, but I was certainly happy to have been invited.) It was chaired by the excellent Professor Martin Knapp of the London School of Economics and we were being asked to think about the implications of ageing on health and social care.

I was asked to say a few words about the impact of longer lives on our ability: “to provide and procure care” although, as I tried to argue, I think this is entirely the wrong way to frame the question. The real question is “how do we support each other as we live longer.”

What I tried to communicate was that there is no evidence that our growing health, and our longer lifespans, will create any crisis. These facts should be a source of celebration. Yet, there is almost no social change, even social progress, which cannot be turned into a crisis if it’s handled in the wrong way.

In my presentation I used data from a report by The Centre for Welfare Reform that we will be publishing in a few months. I had carried out an analysis of of disability, healthcare, social care and community capacity in Barnsley, where:

  • 2% of the population were in very bad health
  • 7% were in bad health
  • 13% had a disability (this group will overlap with the first two to some extent)

Barnsley spent £60 million on social care, however this figure is dwarfed by the care that the citizens of Barnsley provide to each other without pay.

If Barnsley had to pay for the support that is already being provided free, by carers (the official jargon for family and friends) then it would have to spend about £600 million. In other words the support provided by families is about 10 times greater than the support paid for by the community via taxation.

Furthermore, we can go on to estimate how much time and energy is potentially available to the town – what we could call its ‘community capacity’. You can do this by looking at how many people live in Barnsley (about 250,000) and then taking away all the time spent on being a child, time lost to paid work, time in education, time spent caring and time used for ordinary amounts of rest and leisure. This leaves you with an estimate for how much ‘community capacity’ is available. For Barnsley that is equivalent 65,000 whole time equivalent people, with an economic value of over £1 billion.

There is an army of community capacity potentially available to any community (unless its working too hard) and this capacity is probably over 20 times greater than what is spent on social care.

We are society with immense financial wealth, in addition we already have all the human capacity necessary to provide the care and support that we need to look after each other. We will all go through the shared human experiences of sickness, age, disability and death; but we certainly have the resources necessary to ensure that we can all do this in ways that ensure our dignity and mutual respect.

If we focused on our immense community capacity available then there would be no sense of crisis. However community capacity is undermined by a series of negative factors that are driven by Government policy and by the interests of the powerful:

  1. Cuts to social care – Local government funding from central Government has fallen by more than 30% in 6 years and is projected to fall further. Central Government funding used to provide 75% of local government finance. Cuts to social care have been deep and we have seen the number of people supported fall by well over 30% in the same period. I assume that local Government has had to cut its most efficient and low cost supports first, leaving it with a growing percentage of its budget invested in expensive and institutional provision, which is harder to cut. I do not see how the obligations of the Care Act 2014 can be balanced with the desperate situation of local government.
  2. Means-testing of social care – The extreme means-testing of social care does what all means-testing does – it reduces social solidarity and encourages people to divest themselves of their own wealth if they are at any risk of needing social care. This further undermines community capacity and faith in the community’s capacity to support people to get the necessary additional finances they need when illness or disability develops.
  3. Inequality and poor productivity – The UK is the most unequal country in Europe with low productivity and high employment rates. Or to put this another way, more people are having to work longer hours to maintain even a very modest income. For instance, increasingly both partners in a typical family need to work to maintain a modest income, leaving less time for caring or for citizen action. Economic inefficiency and extreme inequality both have the impact of minimising available time for citizen action and community capacity.
  4. Workfare and the collapse of the voluntary sector – There are two powerful but inane dogmas that dominate public policy in the UK: (1) the only useful activity you can do is earn a salary and so pay taxes and (2) the best people to find people work or volunteering opportunities are the DWP or their private-sector agents. Clearly these ridiculous assumptions undermine our ability to tap into people’s real gifts and skills.

So it seems we are in the process of turning what is an opportunity for a longer richer lives into a severe social crisis. We lock a higher proportion of our increasingly limited financial resources into professionalised and institutional care; so we will then be only able to offer support to fewer numbers of people who will be in severe crisis. Alongside institutional care, micro-institutionalisation and the misuse of technology to ‘keep people safe’ will probably grow. At the same time fewer families will feel that they can afford to take care of their own relatives and will so demand ‘care’ from a system that will not be able to offer them support until they reach breaking point. The ongoing pressure to allow euthanasia is consistent with this crazy system problem.

The sad thing is that, while there are so many clever and well intentioned people in the central and local government, it just seems impossible to shift discussion away from the minor problem of ‘funding social care’ to the major opportunity of ‘supporting community capacity.’ It is cynical to think that this is only because a crisis is much more useful to the political elites, but Mencken’s often quoted proposition does sometimes feel so true:

“The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary.”

Perhaps, but I hope this is not true, the powerful do not want to recognise that releasing community capacity is about freedom and empowerment. The real solutions we need – those generated by people, families and communities – all require freedom and creativity in order to exist. The great innovations we are seeing from organisations like PFG Doncaster, WomenCentre, IBK Initiatives, Best Buddies UK, and so many more, are all rooted in an awareness that we are free citizens who can choose to act to benefit ourselves and our community.

Capacity is rooted in the actions of free citizens, working together in community. Such capacity cannot be bought, it cannot be bossed, it can only be enabled, supported and liberated.

Despite my fears it was encouraging that so many in the discussion did share my sense of disquiet at the danger of accepting inequality and an on-going public service crisis as the inevitable background to policy-making. But one could still feel the gravitational pull in our discussion of these hobgoblin problems: the fear of increased costs, the fear of increased rationing and fear about what will happen to us at the end of our lives.

After this discussion I was lucky enough to be invited to East London Radio, to be interviewed by Mervyn Eastman. Mervyn Eastman is an inspiring leader and social worker who has established the Change Agents Coop with the wonderful Cheryl Barrott. The Centre for Welfare Reform has recently joined the Coop as an organisational member.

Together we discussed how the idea of citizenship must become central to our thinking about ageing. Citizenship, everyday citizenship, is the foundation for building a good life for ourselves and building good communities together. We explored how old age was not a problem; but a society that insists on treating it as a problem will certainly end up creating one.

What made this radio interview especially sweet was that I was able to indulge my love of music. A rather sad admission on my part is that I have always dreamed about what I would choose if I was ever invited on Desert Island Discs or on Radio 3’s Private Passions. For East London Radio I picked:

  • Communication Breakdown by Led Zeppelin
  • The Nightwatch by King Crimson
  • Anyway by The Roches
  • A Survivor from Warsaw by Arnold Schoenberg

As I left the studio, to head home to Sheffield, I found myself in the community cafe and bookshop that was also the home of the community radio station. On the shelves were some fantastic European novels I’d not heard of and so I indulged myself by buying 4 books to take home.

So my day ended with this sense of contrast. On the one hand, in the bowels of Whitehall, intelligent people were struggling, against the grain, to stop the system turning old age into a new social problem. Meanwhile, on the streets of East London, ordinary people were busy building, sharing and supporting one another to lead richer, better lives.

As ever Christ’s words help. The Vulgate puts it as “sufficit diei malitia sua” which could be loosely translated it as: Start by tackling today’s injustices.

If Government really wants to help us ensure that we can take good care of each other in the future then there are four pressing problems it could tackle now:

  1. Protect social care funding
  2. End social care means-testing
  3. Radically reduce income inequality
  4. End the stigma and control of the DWP’s benefit systems

Do those 4 things and human capacity will flourish and many of tomorrow’s problems will never arise.

Medical Power & Personal Health Budgets

The modern doctor evokes respect and awe, mixed with some fear and suspicion. At the most basic level a power relationship starts to exist as soon as we feel that another person holds in their hands an important key to our own life, death or happiness. We feel that we need them and this gives them power. However modern medicine reinforces this age-old pattern of dependency further because of the enormous progress made by modern medical science; progress which is underpinned by an interlocking system of research, education, accreditation, power and money. So, to put this another way, for thousands of years doctors have had power over patients; but since the development of modern medicine in this power has grown considerably – because modern medicine really works.

Ultimately Personal Health Budgets cannot be understood without thinking about this relationship, because it is an innovation within the doctor-patient relationship. It is not an innovation that effects everything in medicine directly; for there are many areas of modern medicine where the use of Personal Health Budgets would be entirely inappropriate. However it does create the possibility of a new kind of partnership between doctors and patients – at certain points – and as such this does start to change the whole relationship.

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