What the Dickens? Individuals, systems and hopes for the green paper

Peter Hay

By Peter Hay

One of my favourite quotes is from Dickens’ ‘Bleak House’ where the worn down and enraged Mr. Gridley erupts with “the system! I am told, at all hands, it’s the system. I mustn’t look to individuals. It’s the system.” Dickens’ landscapes are blotted out by a pervasive fog. Mr. Gridley blew up over a legal matter that had gone on for so long no one could remember what it was about as it disappeared in the fog of opaque Victorian systems. Today, the mechanisms for our twenty first century social care system are shrouded in such complexity that a Coroner in the death of Richard Hadley concluded that he couldn’t find neglect. We have got to the point where the need for a proper diet, a poo and a relationship which supports people with living independently is hidden by the ‘complex.’ This has a broader resonance: the Competition and Markets Authority find that our reticence to face frailty means that we make decisions about a complex care system at crisis points in our lives. Complexity cannot be a fog covering the social care system in the 21st century.

The case for change won’t be made by talking about big and complex systems which Mr Gridley found so dangerous to his health. That doesn’t negate the need for ‘big’ or system reform. However, starting the debate about a social care system often overlooks that it is a broad, inclusive sector that has a huge number of component parts.   I am not sure there is an agreed definition of the words ‘social care’ albeit its purpose in supporting great lives has become more unified. Social care is therefore one mighty big system, but as it is also made up of lots of smaller systems, it’s not surprising people find it complex. Bluntly, it is fog. It’s not just the British system either; a recent tweet from Dr Judith Smith about the complexities of navigating the care system was joined by people with similar experiences in Australia and Germany – and I’ll add Northern Ireland to the mix, which is supposedly a single system.

We have to start by putting a stop to seeing people as passive beneficiaries of what comes off the end of system design. When a Coroner or the Competition and Markets Authority find these systems complex, then it must be axiomatic that leaving people in charge of navigating and buying their own care is also doomed. These debates can become locked into language about client, customer or citizen. It needs unlocking by a recognition that none of us have faced a world so populated by older people before. No one has unique skills and knowledge to design responses to the welcome but unprecedented demographics and health services that we now live with. The green paper would do well to start by being clear that government cannot know the unknown and commit it to navigating with us through these unchartered waters of human development. Knowledge and resources are maximised when they are shared. The system needs all the resources, skills, insights and talents that people bring with them. The system and the individual need to look to each other.

Mr Gridley failed to see that systems start with the individual. I found in social work a profession that offers care and support to people whilst recognising that our lives are shaped by the systems around us – families, friends and communities to name a few. Social work is about the individual and the collective, just as it is also about the head (evidence, methods, models and knowing ‘stuff,’ like the law) and the heart – ‘empathy’, friendships and love.

As a social worker, one of my favourite ‘tools’ was to get people to draw how they saw themselves in their system. When asked what makes for a good life, people talk about housing, transport, companionship and a multiplicity of barriers, like the benefits system, that they face in staying connected to communities. People in later life also talk about faith, belief, loss and a living with new timelines for life.

These are our own set of systems, which as people live interdependent lives, nestle within each other like Russian dolls. These matter deeply to us as part of who we are and how we see ourselves, and where they have broken completely, the resulting loneliness now represents a major threat to health. A lack of company kills. We all have networks of connections which might need repair or restoration at points in our lives. Evidence on ageing suggests that wellness is promoted even for people with complex multiple conditions, where people hold on to a sense of their personal narrative and their connections to others. Working with people’s systems and stories promotes better lives.

The green paper is a chance to take approaches that define the system as starting with the personal, but to also recognise that this needs a collective, civic, framework. To support our systems, we sometimes need fearless advocates, champions for rights and those who can hold a laser like focus on what needs to be changed to make lives better. We used to talk about social work in these ways, and perhaps need to revisit its role in making systems personal and clearing complexity. The experience of those self-funding their care is proof that we cannot just leave individuals and markets to somehow work things out. Reverting to the Russian doll analogy, we need as people to be both at the precious centre of everything, but also have the individual as the layer we see first.

The green paper is an opportunity to set out some ambition to be a country that makes ageing and living well possible by harnessing the combination of individual and state power to work with the grain of what life has made us. Quality Matters asked us to aim for ‘a seamless service for the person not the system.’ We need to reset an approach around what we need to grow old well, or to live well with disability. We can build upwards from what we need to maintain and thrive within our personal system to address the many parts of a ‘whole systems’ approach.

Mr Gridley was trying to work out how to hold the system to account for overwhelming him. He would still rage today, particularly about failures for those who were held in the trust of the ‘care system.’ A poo, or the companionship of others, doesn’t seem like too much to ask, but our current system hasn’t delivered them. It’s not just the social care system that is hiding individual need behind the fog of complexity: health systems are also part of this – an indeterminate trolley wait in a corridor is not compatible with an aim to be a great country to grow old in.   We could go on and talk about transport…but this is where systems reform is endless, too big and too complex and overwhelming, so requires the switch in focus back to people and individuals and to systems as constructs in the lives of people.

I want system reform, based upon a guarantee that systems will work with me and mine. I want to be assured that systems will treasure the individual at the centre and the front of the Russian Doll. I want some assurance about a fundamental set of rights and how these would be upheld if I become frail. I want to hear how the system will support the uniqueness of my world (its systems), not replace them, and build the best life possible. The green paper is a chance to make start by making commitments to always and everywhere working together, so that we blend systems and individuals. Given the sorry history of failures to reform social care, the green paper needs to lift the fog by spreading belief that reform is possible. If it does that, it will save a few modern day Gridley’s and more importantly start to make it possible to be more certain about how our care would be delivered should our present or future frailty need us to trust the system.

This can be done. The #socialcarefuture initiative is about growing the future out from the glimpses of it that we see right now. I see examples some of these in:

  • the way the older people can build communities and networks of support around an infra-structure of housing support
  • some of the really great personalised care planning that really understands  what people like and need. My favourite example is when getting beyond why x was the person’s favourite support worker, we found out that there was right way and a good time for serving a frothy coffee. It’s those little details shown in the control of daily life that are the expression of individuality.
  • the contribution made by faith groups and others who, without state funding, work tirelessly at the connections between people. I am watching now in my own community some amazing support around a terminally ill man

We need a system that facilitates these kinds of things, not hinders them

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