Patients as people
Every country in the world seems to have a healthcare crisis. The problems are particularly severe in rich and ageing countries, including the United States and the United Kingdom, where expectations are especially high and the systems were designed for a different reality. A new report from The King’s Fund, a British charity, suggests a better approach.
The policies proposed by the independent Commission on the Future of Health and Social Care in England, chaired by economist Kate Barker, are designed for the UK. However, the basic idea is universal. Barker says that the two largely separate arms of the welfare state – healthcare provision and direct financial support for individuals in need – should be merged.
The two used to be quite distinct. Healthcare dealt with illnesses and the largely short-term treatments provided required doctors, nurses and, more rarely, hospitals. Welfare programmes assisted the ill, but their chief objective was to counter economic and social problems such as unemployment or dysfunctional families.
Now, as the Barker Commission points out, a fairly high proportion of the population is in need of constant attention that is simultaneously social, economic and medical. Older people, say, with serious handicaps such as dementia need help. But not just medical help. An increasing number of younger people have complex conditions, such as those associated with drug addiction, in which the physical problems both cause and are amplified by social difficulties.
Before the advent of the welfare state, families provided most of the non-medical aspects of care for people in need of aid. With birth rates falling and paid employment rising, the supply of unpaid carers has shrunk. The welfare system has been left to fill in ever-wider gaps.
The separated medical-social arrangement often works badly. Frequently, expensive medical care of doubtful value is provided but insufficient resources are spent on supportive surroundings and leisure time for loving carers. Almost always, there is a labyrinth of bureaucracy to get through before anything approaching the right mix of care and money can be obtained.
Barker’s group calls for simpler “pathways” to care. The details of merged medical and social programmes rapidly get complicated, as is unavoidable in a system which tries to be fair to millions of people, most of whom will be discontent with any affordable resolution. But the basic idea is a good one. Care should be unified, and the medical experts should only be in charge when they have the most to offer. For many people in the care system, the desire for a supportive environment is paramount while medicine may offer little more than palliative care.
If applied wisely, this approach could lead to the holy grail of modern government, better services for less money. A care-led approach would also harvest more of a valuable and inexpensive resource: human generosity.
For example, many seriously ill people would like to spend more of their last few months than is currently possible cared for by a family at home. That is generally much cheaper than hospitalisation. Long before the end, relatively modest financial support for the families and neighbours of people in need could well delay entry into expense residential institutions.
Familial love is an economic force that does not appear in the Barker recommendations. That is hardly surprising, as her commission was charged with the study of the operations of bureaucracies. Love and bureaucracy may always be precarious partners. Those who are personally connected with a needy citizen may be best placed to offer the most appreciated support, but will often bristle at the rules and procedures which are needed for any centralised system to run smoothly.
There is no way to eliminate the bureaucratisation of care in modern societies, where professional medical attention is expensive and families are often unable or unwilling to take care of their weakest members. Still, it is worth making a social effort to support an approach which is more personal and less medical and institutional.
The goal should be to maximise what is sometimes called subsidiarity. This is the principle that matters should be handled by the smallest, lowest or least centralised competent authority. Subsidiarity fits especially well with the care system. As far as possible, decisions should be made by the people in need and by those who know them best, and love them most unselfishly.
The fairly new British practice of personal budgets, which give more choices on spending to patients and their families, is subsidiarity in action. The Barker Commission rightly praises this approach. The goal, in the UK and elsewhere – is to make personal care more caring and more personal.