WORK IN PROGRESS

Negotiating Partnerships –
some reflections of our fear of the vulnerable in health and social care

Tim Dartington

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I want to describe briefly a way of organising care around vulnerable people living at home. It is not that different from what may be happening anyway at times, but I would like to explore if it is really possible to plan for a way of working that would meet the needs of vulnerable people for continuity and consistency in their care. Having described what I have in mind, I want then to look at the issues this raises in the real world of health and social care in the community.

Home care – an integrative way of working

I would like to see an integration of formal and informal systems of care – eg, by thinking of very small networks equivalent to an extended kinship system. This idea comes out of six years’ close observation of the care of a person with early onset dementia. By a process of trial and error, an effective support group came together around her care, even as her needs increased. This support group included local authority home care workers, agency workers, untrained carers from Eastern Europe, who were directly employed, a domestic cleaner who became a carer, and informal carers (family and friends). They were all looking after other people as well. This ad hoc illustration of what works in practice proves a template for what might be planned and replicated around the needs of a vulnerable client. For example, I would think of a cluster of three or four clients, and a home carers group of, say, ten or twelve. The group would work flexibly with the clients (and their family carers, where appropriate). They would provide services according to agreed care plans, but they would do so in a self-managing way, like informal carers.

If a client were in particular distress at one time, the care system would be able to respond immediately. If a client is not needing support at a particular time, for example, during a family visit, this would release the care system to focus their energies elsewhere.

This model would meet the need for consistency and continuity that clients are wanting – and which is difficult to provide through a conventional system, where carers are rotaed on a daily or weekly basis by their managers. The group would be able to manage its own absences - holiday and sick leave, training days, etc, and senior managers would only be involved where there system was showing signs of not being able to cope.

Such a carers group might be supported by a pair of team leaders (part-consultant and part-manager), who would not be working in a directive way but working to maintain the capacity of the group for self-managing.

What is special about this simple example?

This is an example of a negotiating partnership model of care. (Isn’t partnership always about negotiation? Up to a point: ‘We provide certain services, as laid down’ ‘these the hours we work’, ‘these are the eligibility criteria we follow’, etc.) Negotiating partnership arrangements test the constraints of pre-existing system differences.

A difficulty with a negotiating partnership model is therefore that it is deviant according to command and control managerial structures and linear accountability systems.

It follows a principle that authority comes from the task In many aspects of our lives, we do what has to be done. It should be possible to apply this principles to service delivery around vulnerable people.

What is difficult to accept about a negotiating partnership model of care?

I remember the story of a consultant geriatrician who would take a screwdriver on domiciliary visits. An alternative might have been to refer to occupational therapy, who would make an assessment visit towards the end of a performance monitored three month waiting period, and then refer on indefinitely to a technician to fix a wonky table leg.

The point of this anecdote? There are still carers who will say they don’t do the washing up or buy a loaf of bread, or are told by their managers not to take their clients out in the garden, because the local authority would be liable if they have a fall. So how do we allow for this kind of authority that comes from the task in a negotiating partnership model of care, without undermining the very necessary controls that have been established over time to protect vulnerable people from exploitation and abuse?

The negotiating partnership model provides the conditions for the effective use of resources according to need, with continuing revue of good practice, while providing continuity and consistency of care and reducing social isolation. But at the same time it does not in itself protect against the possibility of inefficient use of limited resources, inequitable distribution of resources, the uncontrolled spread of self-serving restrictive practices disguised as good practices, and the unregulated abuse of vulnerable people – all the things that recent reforms in public services has been introduced to address.

The dilemma about managing a responsive system

We are still having to square the different views of human nature at work that Douglas McGregor described as Theory X and Theory Y. Treat people as immature and dependent and they will respond accordingly. Treat them as responsible adults and they are more likely to be so. The challenge is to balance the right amount of direction with the optimum level of autonomy. You need controls and monitoring to ensure good performance but you also have to authorise and acknowledge good performance as it happens.

Group dynamics and the reparative delivery of services

None of the basic assumptions famously identified by Wilfred Bion in his study of Experiences in Groups –an unconscious group identity momentarily built around the need for dependency, fight-flight or pairing - is in itself unhelpful for a group working with the needs of vulnerable people. A work group may meet its unconsciously expressed needs and also do a good job.

I would like to think about an hypothesis about reparation and the delivery of services, put forward by Paul Hoggett at the OPUS conference 2005: that those who choose or find themselves in caring or therapeutic roles are motivated in part by an understandable internal need to make things better, to relieve suffering, to alleviate any distress in others, and that this is because of their own experience of distress in themselves and others. Hoggett has found this kind of motivation is often put forward by those explaining why they entered careers in nursing, social welfare, medicine, and allied professions.

Such motivations are not easily expressed openly and there may be a fear that they will be subjected to a cynical or contemptuous attack in a so-called ‘me society’ culture. Also other motivations are present of course at the same time and may have equal or greater weight: the need for recognition and status, for example, linked with societal anxiety and the need for material wealth.

Management and the reparative function

Where the reparative function within a caring group is damaged or disabled, then behaviours that are, on the face of it, benign and therapeutic, are likely to become indifferent or even cruel in relation to the needs of a vulnerable client population.

The reparative function is damaged, where management systems are disrespectful of the motivation to ‘do the best we possibly can for our clients’. This is the formulation of primary task used by a colleague Tony MacAffrey, when working with health and social welfare teams on issues of performance management. After all, who could argue against such a task? And yet care systems seem to find all kinds of ways that stop them doing the best for their clients.

Management practices, which would seem to be necessary and reasonable in themselves, may nevertheless be destructive of the reparative function, if they are shifting the emphasis too much to an instrumental or survival anxiety state-of-being.

This shift serves a purpose. Make the relationship instrumental and it is more easily controlled – the fantasy is that you can make people more efficient, etc, through the use of protocols, ‘agenda for change salary reviews, inspections, and audit. This is a machine model of a system that works until it breaks down, a systems model that suits politicians, because they also like to feel they are omnipotent until they are voted down.

This approach also addresses a related anxiety that the autonomous worker, doing what he thinks is right, is out of control, like a loose ball bearing in the works. To the extent that this problem of out of control professional competence (and incompetence) has been successfully tackled, eg by general management in the NHS, we should expect to find a corresponding level of low morale – which is what has happened. The reparative aspect of the work has been diminished to the point that people say, ‘this is not what I entered the profession to do’, while finding that they continue to be under attack as ‘forces of conservatism’. Politicians, taking an instrumental view of wage rises for nurses, are confused when the are slow handclapped for their pains.

How the weak threaten the strong – the globalisation argument

This argument has then to be put in a wider context. The question about the modernisation of public services is not whether this is useful or destructive in this or that aspect – we can see that realistically it is a bit of both – but why it has been thought to be necessary for the survival of our economy. I suggest that there is a real fear that the needs of vulnerable people threaten to be overwhelming to the rest of society. It is the threat that is hidden away in the Beatitudes, that the meek shall inherit the earth (not that there is much evidence of that happening). It is the fear that every family experiences, when the question arises, what do we do about mother/father, Uncle Bill, now that they are unable to look after themselves? It is the fear that the industrialised North has of the desperately poor ‘third world economies – if we took their needs seriously, our own way of life would be seriously depleted. The economist Andrew Glyn has described how welfare states in industrialised societies are to be dismantled to meet competitive global demand.

So the idea that has become a mantra, not to be challenged but repeated at every opportunity, is that public services have to be as responsive to the need for change as any other enterprise in the global market. (This is why business entrepreneurs are de facto thought to be good at running schools. Perhaps they are, if schools are to be thought of primarily as businesses competing with others making a profit out of youth culture. Just as educationalists might have something to offer to running businesses, by bringing their experience of working with a dependency culture into what is otherwise seen exclusively as a fight-flight economy with its unforgiving need for successive short-term gains.)

The cost to the vulnerable

While the need for responsiveness is always there, as you can never control for changes in a turbulent environment, this is not by itself a lot of help in thinking about the needs of vulnerable people having to live with their diminished capacity to be responsive to change.

Instead what we are seeing is that the most vulnerable members of society are having to live with the anxieties of those much more powerful than themselves. In thinking about societal dynamics, we may ask about the underlying anxieties that are being manifested in our social systems, does one size fit all? Or is there a fear directed towards the weak by the stronger, so that those who have most to lose are most afraid of losing it? The sad injustice of this is that the weak can live with being weak if we let them, but the anxieties of the more powerful undermine all the time that capacity of the vulnerable to live life on their own terms.

A working definition of a vulnerable person is one who through personality or circumstance is more vulnerable than we think is right in a stable and well-ordered world – more vulnerable than us, in effect. In the end, the worst disadvantage that the vulnerable have in relation to the rest of us is that by reminding us of their weakness they make us feel anxious and guilty about our need to survive at their expense. I feel so bad about not phoning my poor old aunt that I don’t phone her again today.

All of this contributes to explaining a context, in which the simple scenario I outlined at the beginning, of a small group of peopled being left alone to look after the needs of a vulnerable person, is unlikely to happen without a struggle.


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