Beyond Efficiency: Care and the Commons
Author: Thomas Allan
Current welfare policy is dominated by a pair of narrowly defined and contrasting concepts: the 'public', which is usually equated to the state, versus the private, which is treated as equivalent to narrow economic self-interest. This is an unhelpful framework for thinking about the welfare state as a whole and social care in particular. Thomas Allan, in this important essay, challenges the current thinking about care and asks us instead to return to an older and more useful conception of care - as part of the commons.
Care is something intrinsic to being human; a part of the human spirit that doesn’t lend itself well to the institutions we have created and the norms to which we are accustomed. Take its management, for example:
- How would we measure care?
- Can care be efficient?
- Can we optimize care or maximize returns on it?
- How can we incentivise others to care?
This is an economic or managerial representation of care; one that sees care as a transaction or economic process, and questions that revolve around policies that construe citizens as rational economic beings in every field of life – something that is profoundly misleading (Habermann 2012).
To care is to be intuitive; to perceive the intangible and experience the imprecise, formless, confusing and the painful dislocations; as well as the warm, comforting and reassuring. Care cannot be categorized, counted or separated for purposes of analysis, and includes attachments to time and place, patterns of life and thought, reproductive activities and habits of the heart (Harvey 2007) – something Denis Postle has termed a "Wilderness"(Postle 2016).To understand this wilderness is to perceive complexity and adopt a fully holistic approach.
Yet trying to care in a system that doesn’t is a thankless task. Bureaucratic systems legitimise poor standards (Jackson 2015). The marketization of care leads to repressed wages for frontline staff (Jackson 2015). Thoughtless and inhuman policies are leading to "a new wave of institutionalised practice," and the ongoing managerial drive for cuts and ‘cost efficiency’ leads to organisational failures as well as personal crises (Jackson 2015; Griffin, McGrath & Mundy 2015).
The government pays lip service to ‘Big Society’ and ‘Strong Communities’. But in truth, our capacity to organize networks of mutual care is being endangered by the pursuit of economic power and political goals about which there is no real debate beyond the palliative consultation.
Part of this is that, as managers or employees, we seem to have fallen foul of the McNamara Fallacy: making decisions solely on the basis of what can be measured – something a management colleague once described to me as "looking through the wrong end of the telescope." Seeking to reduce care to manageable proportions, we have become blind to the more intricate patterns of human interaction that are subtle, qualitative, long-term and complex (Bollier & Weston 2012).
In health and social services, management and professional services resemble a closely related exercise in the art of gate-keeping: extracting information from people who need support and their families to populate over lengthy and technical assessments, before data inputting into vast IT systems to ‘evidence’ preordained decisions on cost savings. Can you communicate the bad news nicely to the distressed and the disenfranchised? We speak of the person centred principle in our work, yet people are made to fit the system rather than the other way around.
The tendency has been to reduce care to the measurable and the technical, targeting the isolated individual. This thinking reduces personal experiences such as mental distress and social marginalization – challenges relating to the social environment in which people live (Griffin, McGrath & Mundy 2015) – to technical tweaks, ameliorative revision or, most perniciously, resorting to deficit based thinking and victim blaming (Ryan 1971) – problematic or maladapted individuals. It is blind to the social contexts in which personal and organizational issues arise. This is especially problematic when we are trying to promote a more caring, inclusive society.
In many organizations, foundational and much fetishised principles of management such as efficiency have taken on turbo charged and fanatical proportions, reinforcing the view that improvement in care is a question of ever more efficient resource allocation. Social economist Mark Lutz wrote presciently:
"One could see the present age as dominated by a religion of economic efficiency. Everything is to be interpreted in its light. Institutions must justify their existence in the name of efficiency, the state itself being no exception" (Lutz 1999).
Principles such as market competition and optimization dominate the debate, leaving little space for democratic decision-making, or critical reflection on the lived experience of people in their everyday lives; two vital considerations in the satisfaction of human need (Doyal & Gough 1991; Gough 1994).
In public, private and even nonprofit sector organizations, cost savings, cost efficiency, rapacious downsizing and restructures have become common sense and good business; or, for those less inclined, unfortunate side effects of economic downturn but necessary for survival.
Displaced and bewildered staff are the ‘engaged’ subjects of ‘necessary’ change in response to the ‘inevitabilities’ of economic globalization, managed through faceless systems of performance measurement to deliver efficiency, productivity and profitability to the market. Precarious employment, reduced wages and welfare, stress, anxieties, insecurity and a crisis in public health are all inconvenient ‘externalities’ to the mainstream economist’s efficiency models.
Contradictions and confusion reign. Human bonds are broken. Huge sums are invested in vast data systems to collect information for ‘efficiencies’ in the market, while poorly paid and over-worked care staff leave to be replaced by expensive agency staff or unreliable technology. On reassessing disability welfare entitlement, meanwhile, academic David Stuckler points out that "the government's own estimates of fraud by persons with disabilities is less than the sum of the contract awarded to the company carrying out the tests."
Most disturbingly, while evidence traces the actual human cost of austerity (Basu & Stuckler 2013), key decision makers press on, offering policies based on an impoverished conception of human welfare. Whether constrained within organisational hierarchies or blinkered by free market ideology, we are unable to find a way out of the impasse.
There is inevitably a human consequence of such organization. This political rationality – the logic of the market – imposes itself on our values, shapes our identities and our perception of ourselves and others, in a manner French Philosopher Foucault called governmentality. It extends its influence into our minds, our personalities, and inhibits empathy; isolating us from others (Meretz 2012; Verhaeghe 2015). It threatens the public ethos and reconstructs notions of citizenship in its image. The impact of austerity, belief in free markets and the doctrine of balanced budgets are undermining our human relations: the very bedrock of our free civil society.
But how can we make visible the human relations that underlie care? Is there a more caring alternative? The answer, I believe, lies in the notion of the commons.
Reconceptualising care and the commons
Social activist and author John Restakis points out it is profoundly false to refer to care as a product, or to the recipients as clients. Says Restakis:
"It is the unthinkable urge in a market society to commodify human and social relations. Neither state bureaucracy, which depersonalizes social service recipients, nor private sector firms, which instrumentalize recipients as a source of profit, can ever be suited to the provision of relational goods." (Restakis 2011).
In this sense, care is not a ‘thing’ that we produce and distribute through standardized state systems or impersonal market mechanisms, but connections that are made on the basis of our natural predisposition to love, empathise, reciprocate and share meanings. As Restakis makes clear, both state and market take as its starting point an economistic assumption of deficit or scarcity of care in society, ignoring that care is an intrinsic human response to others in need.
As a set of free market policies dismantle the welfare state and privatise public services, the burden weighs heavy on the public sphere to provide the fix. This is the sphere – an often overlooked and taken for granted sphere sometimes referred to as the ‘commons’ – where community organizes and provides its own services: family carers, civic and voluntary associations, cooperatives, ‘user’ led advocacy or parents organizing their children’s playgroup.
Massimo De Angelis, author and Professor of Political Economy at the University of East London, explains:
We find commons in community organizations and associations, social centers, neighbour associations, indigenous practices, households, peer-to-peer networks, and the reproduction of community activities organized within faith communities. (De Angelis 2012)
But De Angelis urges us to be wary of the always ‘revolutionary’ management strategies we are exposed to, instead asking us to understand commons as an informal social activity from the bottom up known as ‘commoning’. This is where the real ideas for change are conceived and grow.
The Commons – "a vision of empowered citizens taking charge of their lives and their endangered resources"(Bollier & Helfrich 2012) – is a field of possibilities and new social practices, based on sharing, cooperation, reciprocity and socio-cultural change. These practices are providing pioneering solutions to the challenge of how to reproduce our livelihoods beyond market and state.
Yet a ‘commons fix’ (De Angelis 2012) is not a replacement for properly funded public services, so we can turn a blind eye to the social and ecological disintegration around us. To avoid being co-opted into neoliberal narratives of the ‘Big Society’ or ‘Strong Communities’, the act of ‘commoning’ also involves asserting our political rights, writes Brigitte Kratzwald:
Rethinking the social welfare state from the perspective of the commons means stepping out of the private sphere and reclaiming the state and the public sphere. In this context, “state” includes all levels of government, including the federal states and the municipalities. This means that commoners need to consider themselves part of the public sphere again, the sphere of politics. (Kratzwald 2012)
Can these commons really happen? They already are. According to recent publications by the Commons Strategy Group we are already showing an intrinsic desire as citizens "to collaborate and share to meet everyday needs as a powerful strategy for building a more fair, humane social order" (Bollier & Helfrich 2015); from people "organising to defend their forests and fisheries, reinvent local food systems, organize productive online communities, reclaim public spaces, improve environmental stewardship and re-imagine the very meaning of “progress” and governance" (Bollier & Helfrich 2012).
In health and social care, the Dutch Homecare organization Buurtzorg is a managerless network of 7,000 nurses formed by Jos De Blok in 2006. This not-for-profit organisation is drawing interest both in the Netherlands and elsewhere as a genuinely person focused and democratic organizational form, born out of former District Nurse De Blok’s passion and frustration with his profession falling foul to managerial principles of productivity, protocols and administration – losing its social value.
With District Nurses "alienated from their profession," they had become "imprisoned in administrative tasks;" their skill and expertise "barely called upon anymore." Tellingly, De Blok also felt the drive for efficiency was undermining the essence of what care is:
"The cause of the malaise is the product-oriented approach that first appeared around ten years ago in the homecare sector and is, by now, widespread. In this vision, care is seen as a product that you can chop up into various activities. You then try to carry out these activities as cheaply as possible."
Restakis meanwhile presents a model of the social cooperative with improved accountability to people who need support; one that doesn’t compromise the obligations and prerogatives of government, while moving "beyond defensiveness" of the traditional political battles between supporters of either public or private delivery models.
This model is based on an experiment with new ways of funding social care by the foundation Fondazione del Monte di Bologna e Ravenna. It involved 6 key principles, abridged below from his book Humanizing the Economy (2011):
- Shifting the production of social care delivery from government to democratically structured civil institutions, with government retaining its role as prime funder to these services.
- Government funding should flow direct to people who need support who would then select services they need from a choice of accredited organisations. Independent consumer cooperatives should be funded to assist people (e.g. without mental capacity) and their families in the identification, evaluation and contracting of care services.
- Social care organisations must have the legal ability to raise capital from members and civil society more generally on the basis of social investing.
- Surpluses generated by these social care organisations with public funding would need to be held as social assets and a reserve held for the expansion and development of that organisation and its services.
- The primary role of government would be to continue to provide funding for social care and establish the rules of the game, in partnership with service providers, caregivers and people who need support.
- Service design and the assessment of need would take place at the community and regional level of delivery. This decentralisation must include the democratisation of decision making through the sharing of control rights with people who need support and care givers.
These are some examples and a brief introduction to different ways of thinking about care and the means for its provision. In truth, it is unclear what the future holds. We often talk about ‘risk’ in care – risk to vulnerable individuals, groups or organisations – and to some these solutions may seem unnecessarily risky. But what is clear is that we can no longer talk only about risk to one individual, group or piece of the system, but of the failings of the system itself.
When we take a longer term view and understand the consequences of bureaucratic and free market thinking on human welfare, it is arguably more risky to leave things the way they are. Rethinking care should be a priority.
Given the certainty that we will all need care and support as we move through life, we should be very concerned about our leader’s willingness to accept the social consequences of economic ‘improvement’, and the modelling of our care delivery systems on decision making frameworks such as those designed to maximize efficiency in large For-Profits, such as Sports Direct.
The commons gives us a framework and generative power to take affirmative individual and collective action ourselves now, holding decision makers accountable and looking at how we can create, organize and manage our common resources as communities of free people.
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The publisher is the Centre for Welfare Reform.
Beyond Efficiency: Care and the Commons © Thomas Allan 2016.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.