Why do people get so angry when a small local hospital or residential home is ‘threatened’ with closure? Is it because people particularly want to be looked after in an antiquated, poorly-maintained, under-used and possibly sub-standard facility?
Probably not. It might be because they don’t realise that it’s sub-standard – public services are often very reluctant to wash their dirty linen in public. It might be because they don’t understand what the replacement service involves – services are often inept at explaining change effectively. It might even be that the service has got it wrong – has failed to understand the difficulties people will face getting to the new service, for example.
But underneath all these obstacles to change lies the peculiar importance of such services to our communities and our collective psyche. Health and social care are about much more than treating sick people and caring for the vulnerable. They are intensely political phenomena, in the sense that they have been created and maintained by politicians, responding to their electors’ fears and hopes, and can only survive if they continue to do so.
The NHS is perhaps the greatest tribute ever paid by this country to our shared sense of mutual responsibility, and our recognition that we are all potentially vulnerable. We find it deeply offensive that sick people might be turned away from a hospital, or given second rate care, simply because their wallets are empty. And we all recognise that there, but for the grace of God, go us: personal calamity can reduce us all to poverty and dependence.
So health and social care are the ultimate high-minded insurance policy: we protect ourselves, and we feel good at the same time.
But things need to change, and we need to change the face of health and social care. The way we deliver services is still dominated by models and assumptions that date from the 1960s. District General Hospitals and Residential Homes for the Elderly were once a wild aspiration; now they cant cope with technological advance and client choice. Cottage hospitals need to be reinvented, and people increasingly want high quality, tailored and reliable care in their own homes. The trick is to preserve the original values, while changing almost everything else, if services are still to be available for an ageing population.
People oppose change for all sorts of reasons: because they don’t understand it, and because sometimes it’s simply wrong-headed. But they also oppose change because they don’t trust those proposing it, and because the current infrastructure has become an integral part of our perception of ourselves. For many people, grey-suited public sector managers, who understand the price of everything and the value of nothing, pull the strings of service modernisation. Who would trust them? Local hospitals and care homes are tangible expressions of the values which underpin the services – they actually exist. Anonymous bureaucrats, proposing invisible, and often remote alternatives… not very reassuring, is it?
If you doubt the strength of this concern, just look at the ‘save our hospital’ signs outside almost every small town in mid Wales. (In an excess of enthusiasm, one local resident has even painted ‘save our toilet’ on another well-loved public facility!) And yet what these services really need is people marching to demand their closure and replacement by something fit for the new century.
So we have paradox: people want to preserve something second rate, because they care so much about it!
Trust and understanding – the two go together – is the only real key to this problem. Wales has a big advantage here. Being small and relatively homogeneous, with strong communities and shared values, should foster trust and cooperation between citizens and their public servants. The experience of recent attempts at service change often shows that such partnership can’t be assumed: it needs to be worked at.
Written by Professor Marcus Longley
A version of this article appeared in the Western Mail on Monday 7th November 2011