Becoming Neighbours (2)
Updated: 14 hours ago
A Care System Is Not the Same as Being Cared For
My dad (he gave permission for me to use this, I think he’s rather proud of it) who is now in a very good Nursing home with excellent staff who look after his medical and social care needs well. Since he has been in their care some of his sparkle has come back hence this story about his early years at school.
Andy Burnham has made social care his signature cause. In his first weeks as Prime Minister he called England’s system as unfair as American healthcare. He has now promised to put a plan to the country at the next election: care free at the point of use, paid for collectively, in the way we pay for the NHS. He has been arguing for something like this for the best part of twenty years. This month it became personal, when his own father died in a care home.
Whatever you think of the politics, the diagnosis is hard to argue with. People sell their homes to pay for care. Families go into debt. Access depends on where you live and what you own. Staff are underpaid and overstretched. Several governments have promised to fix it and then flinched. If Andy Burnham succeeds where they failed, a great deal of suffering will be eased, and that matters.
But I want to use his pledge to ask a different question, one that sits underneath the funding debate and that no funding settlement can answer by itself. What does it actually mean to be cared for?
Two kinds of care
Think of a man in his eighties living alone after his wife has died. A carer comes in twice a day. She is kind, competent, and has fifteen minutes. She helps him wash, makes sure he takes his tablets, heats something for his tea, writes in the folder, and goes. The system is working. Every box is ticked. And between her visits he sits in a silent house, speaking to no one, for twenty-three and a half hours a day.
Now think of a woman of the same age in a different street. She has similar needs and a similar care package. But the neighbour two doors down pops in most mornings. A lad from the house opposite puts her bins out. On Thursdays someone from the community centre picks her up for the lunch club, where she has sat at the same table for six years and knows everyone’s grandchildren by name. When she had a fall, it was a neighbour who noticed the curtains hadn’t opened.
On paper these two people receive the same care. In reality their lives are completely different. One is being serviced. The other is being held.
What a system can and cannot do
This is not a criticism of care workers, who do extraordinary work in impossible conditions, nor of the ambition to fund care properly. It is a recognition of what systems are for and what they cannot reach.
A system can guarantee that help arrives. It can make that help fair, safe, and paid for. It can train staff, set standards and inspect them. These are real goods, and we should want more of them, not less. They have changed my Dad’s life.
What a system cannot do is make someone known. It cannot make a neighbour notice the curtains. It cannot manufacture the lunch-club table or the grandchildren’s names. These things only exist because people have chosen, over years, to be present to one another. They are not delivered. They grow.
In the first post in this series I suggested that one of the forces thinning out our common life is management by system: the habit of treating every human difficulty as a technical problem with a technical solution. Social care is where that habit is most tempting and most dangerous. Loneliness, frailty and grief do not arrive in categories. Yet the easiest thing for any large system to do is to break a person’s life into assessable needs, allocate minutes to each, and measure delivery. We end up very good at the tasks of care and very poor at the relationships of care.
Care is relational all the way down
When we are frail, what we most fear is rarely the physical difficulty itself. It is being alone with it. It is becoming a burden, an object of provision rather than a person in a web of people. What sustains us is being known: someone who remembers how we take our tea, who knew us before we needed help, who notices when something is wrong because they know what right looks like.
This is exactly what we mean by saying we are made by our relationships. It is as true at eighty-nine as at five. The quality of care in old age depends less on the number of minutes provided than on the density of the relationships surrounding the person receiving them.
Amar Peterman, in Becoming Neighbors, talks about the practice of accompaniment: walking alongside someone rather than doing things to them. It is a helpful word. A care visit is a service. Accompaniment is a relationship. We need both. But only one of them can be commissioned.
A National Care Service needs a neighbourly country
Having been through the system with my dad, I dearly hope Andy Burnham succeeds in building a national care system. But its success will depend on something it cannot create: neighbourhoods where people know one another.
The NHS works partly because it rests on things it did not create: families, friendships and communities that do most of the actual looking-after between appointments. Social care rests on those foundations even more heavily. Most care in this country is not given by the state or by private firms. It is given by spouses, daughters, sons, neighbours and friends, largely unpaid and largely unseen. A care system that ignores this will be expensive and lonely. A care system that strengthens it could transform how we grow old.
That means the reform debate needs to ask not only “who pays?” but “what helps people stay connected?” Community buildings, lunch clubs, local groups, the small places where people meet each other without an agenda: these are not luxuries to be funded once care is sorted. They are part of the infrastructure of care. They are where the relationships grow that make the formal system bearable. Without them, people become lonely sooner, frail sooner and dependent sooner, and the bill for that falls on the very system we are trying to fix.
What this looks like on the ground
One of Toc H’s projects is a weekly group for older people, mostly in their seventies and eighties, though nobody checks anyone’s age at the door. It meets in a community building that was put up over a bomb crater from the Second World War. That feels fitting, since the group is itself a way of building something good on ground that has known loss.
It is run by a woman who is now eighty-seven. Every so often she rings me to say she is too old to carry on, and would I please find a new coordinator. A few days later she rings back to tell me not to worry: she has decided to carry on. I have come to understand both calls. The first is honest about what the years ask of her. The second is honest about what the group gives her.
On the surface, not much happens. They do crafts. Sometimes someone comes in to talk about the war, and memories come out that have not been spoken aloud for decades. Sometimes they just watch a film together. No funder would call it an intervention.
But listen to the conversation around the tea urn and you hear something else. There is a great deal of talk about health: the latest operation, the appointment with the doctor, the nurse practitioner, who always gets a good mention. This is not idle chatter. People are making sense of what is happening to their bodies, comparing notes, reassuring one another, and noticing when someone seems not quite themselves.
The group doesn’t stop when the session ends. During the week they ring each other. If someone is ill, the news is round the network within minutes and a visit is arranged. No referral is made and no assessment is carried out. Nobody is commissioned. People who know one another simply look out for one another, because that is what you do.
That is care in its deepest sense. No care package could buy it. But a good care system could be designed to recognise it, lean on it, and help it grow.
The honest conversation
Andy Burnham says he wants an honest conversation about social care. Here is my contribution. Funding matters and fairness matters, and he is right to put both at the centre. But if we fund care without also rebuilding the relationships in which care is given, we will have built a better system for delivering tasks to lonely people.
The deeper question is not just how we pay for care in old age. It is what kind of neighbours we intend to be to one another long before we need it.
Sources:
**You can read Paul's blogs here.
Comments