Saturday, 12 October 2013

Fight The Power? Personalisation and power in England

Fight The Power? Personalisation and power in England

Chris Hatton

This is my first tentative foray into blogging, and as an academic who generally likes to talk about data and is wary of too much theoretical abstraction this is a weird first blog for me to write. It has been prompted by a question posed by Martin Routledge (currently Head of Operations for In Control) on Twitter, which went as follows (I’ve added some vowels…):

“Reflecting that we are good about talking about personalisation, less willing to accept ways of actually transferring power to people – why? Institutional history of services? Risk averse organisations? Interests of commissioners, providers, staff not same as people using?”
I’ve worked with In Control for over a decade on a series of tools to evaluate the impact of personalisation on people using self-directed support and family members, and variants of this question (“Why do powerful people find it so hard to give power away?”) have never been far from my mind. However, I’ve recently been wondering if this is the right question, and if the very fact of asking the question in this way sets up as adversaries people who might otherwise be allies.

As a minor detour, for the past couple of years I’ve been a PhD supervisor for Dennis Johnson, a retired paediatric neurosurgeon and creator of a paediatric palliative care service in the hospital near where he lives in the USA. For his PhD, Dennis spent some months in Romania, closely investigating a paediatric palliative care service identified as a ‘beacon’ of good care in a country that was, to put it mildly, not conducive to the provision of good palliative care support. Dennis’s thesis (which passed last week – many congratulations, Dennis!) contained an eloquent description of the features that made the service a beacon in difficult circumstances, but it also contained an analysis of how the service had managed to negotiate its way round the hostile power structures that existed in Romania for this type of service.

Rather than seeing power as a property of certain individuals or institutions, Dennis introduced me to a set of dictums formulated by Michel Foucault, the French philosopher with an abiding interest in the exercise and effects of power throughout societies. One interest of Foucault’s was in how challenges to patterns of established power or authority have historically been successful, and he came up with 6 common features of such successful challenges. Given the formulation of the personalisation project in England as a challenge to established structures of power and authority in social policy and service provision, I thought it might be useful to see to what extent these 6 dictums apply to the development of personalisation in England, and whether there are useful lessons to be learned for how (or if?) personalisation can develop into a meaningful reality for everyone.

So, here goes…

1)     Avow ‘transversality' or transnational citizenship.
Foucault’s first dictum suggests that ideas that change the world do exactly that (at least partially) – they are thought of as international and beyond a certain point inevitable and part of the common sense architecture of how we think. As Sir Charles Geoffrey Vickers in 1958 wrote (in relation to public health) “The landmarks of political, economic and social history are the moment when some condition passed from the category of the given into the category of the intolerable”.

In terms of what Foucault’s first dictum might mean for personalisation in the UK, my question would be to what extent personalisation embodies broader changes in international expectations about what is acceptable and unacceptable in the way societies support all their citizens. For good reasons (see below), the personalisation project in the UK has largely focused on the mechanics of implementing personalisation within existing legal, policy and service frameworks. However, there are at least three risks entailed in such a focus, and there may be advantages in placing more public emphasis on the alignment of personalisation within broader movements of ideas.

The first risk is that the focus on the mechanics of personalisation leads to the perception that personalisation is an end in itself, rather than a range of vehicles for helping people achieve self-determination. The second risk is that the focus on service systems leads to a UK-centric view of personalisation, which risks losing the connections to broader international movements towards self-determination. The third risk is the perception that personalisation in the UK has over-stated its originality and not paid due regard to the national and international currents of thought and practice that fed it.

In my view personalisation gains strength from taking its place as one part of a broader international movement focusing on the rights of all citizens to self-determination. These broader international movements can shape how societies think about what is ‘given’ and what is ‘intolerable’, in ways that any national programme cannot.

2)     Target the effects of power rather than confront the sources of power and authority.
On my very cursory reading of Foucault, one of the few things that stuck was his notion about power being networked, without an obvious ‘centre’, such that everyone in the network feels (in different ways) constrained and relatively powerless. While it is tempting to imagine a cackling megalomaniac pulling the strings of power (or sitting on a huge sack labelled ‘Power’ and refusing to give any of it away), perhaps the reality is more like the Wizard of Oz – a sad little man sitting behind a curtain frantically trying to convince us of his omnipotence.

This isn’t to say that differentials in power are not stark and are not real – clearly a person trying to negotiate the social care labyrinth is all too often forced into a place of screaming frustration. But it is to say that if we go searching for the person with the sack labelled ‘power’, with the aim of persuading them to give it up or taking it from them, we’re going to be searching for a long time. When I listen to and read the accounts of a lot of people involved in social care, including people using it, people denied it, families and friends, social workers, managers, proponents and opponents of personalisation, and even politicians (‘Why won’t the world just do what I tell it?’), I don’t hear anyone (well, hardly anyone…) rubbing their hands with glee at the power they are managing to retain and the joy with which they wield it. 

To use a wildly inappropriate metaphor, my sense is that many proponents of personalisation see themselves as an insurgent force (think the rebels in Star Wars), but instead of blowing up the Death Star they are seeking to persuade the Stormtroopers to dismantle it themselves and give the parts to people to build their own (non-lethal) homes. There is a question about whether this is possible without trying to kill Darth Vader first (I suspect every reader will have their own candidate in mind for the Darth Vader role), but Foucault’s second dictum does suggest that working systematically through the policy and practical barriers and their consequences for people is likely to be more effective than all-out confrontation.

Of course, the rapid adoption of personalisation as government policy in England has greatly complicated how the personalisation project can be viewed in terms of power – if personalisation is an instrument of government policy can it stay true to its radical principles – have the Jedi been turned to the Dark Side of the Force? Again, Foucault’s second dictum would suggest that such accommodations are necessary as long as the personalisation project stays focused on understanding the effects of systems on people and how personalisation can make a meaningful difference. Attempting to directly confront political issues such as the distribution of resources is unlikely to be as effective as tracking the impact of these political decisions on the lives of people using (and not using) social care and/or personalisation and trying to persuade people to do something about it.

3)     Contest the privileges of knowledge (and contest what is privileged knowledge).
Much of the debate around personalisation rests on a sometimes acrimonious contestation of what counts as evidence for what is ‘really’ happening with personalisation. Academic research, individual and family accounts of their experiences, case studies of organisational change, surveys, and statistics are all being generated in increasing quantity and variety around whether, how, why, and for whom personalisation is working (or not). As someone who has helped with the generation of some of this evidence, I find the diversity of types and sources of knowledge a real asset (in fact, absolutely necessary) in trying to understand the complexity of personalisation and its effects.

However, I feel the debates about personalisation are all too often bogged down in attempts to privilege one type of knowledge over another. For example, academic researchers can appeal to methodological rigour to claim that only knowledge produced in this way can be relied on and everything else is anecdote, and individuals producing detailed accounts of their own experience can claim that only lived experience counts and academic research is too remote from what’s really happening on the ground. And these disputes about what counts as ‘knowledge’ often have power, or perhaps more aptly a sense of powerlessness, underlying them. People may feel that their lived experience is unheard and ignored, amplifying a general sense of powerlessness in relation to service systems. It may be a surprise to know that academics feel about their research in a remarkably similar way!

For me, Foucault’s third dictum suggests that we need to contest the idea that any particular type of knowledge is in a uniquely privileged position, and learn what we can from all the sources of knowledge at our disposal by putting them alongside each other and trying to synthesise what we can learn from them rather than seeing them in oppositional terms.

4)     Engage the immediate problem rather than the “chief enemy”.
For me, this is closely related to Foucault’s second dictum, and has helped me to think about the frequently acrimonious debates around personalisation. Partly because pretty much everyone feels (in their different ways) powerless and frustrated with how things are, there is a temptation to identify someone else as the ‘enemy’ who is the barrier to a goal that seems to be generally agreed, that of meaningful self-determination for everyone (see Foucault’s sixth dictum below).

The first problem with this is that people are often identified as enemies who could be allies and actually have a shared goal – do debates about how this shared goal can best be achieved need to become adversarial shouting matches about who is to blame or whose motives are the most noble?

The second problem with this is that it might make us feel better (although at the expense of making someone else feel worse), but where does it get us in terms of the goals we want to reach? If we make social workers feel that they’re oppressive stuck-in-the-muds who are stopping people get what they want out of life, does this help us understand why things are the way they are and what social workers feel about their role? If we make proponents of personalisation feel like they’re wilful Pollyannas who are pushing an agenda with no actual regard for the realities of people’s lives, where does that get us?

Foucault’s fourth dictum is a real challenge, as it suggests that campaigning against the iniquities of power is not enough on its own, and also that grand theories providing overarching solutions to problems of power are unlikely to be found (and are even more unlikely to be useful). Foucault suggests that there needs to be ongoing, practical engagement with existing power structures focused on solving ‘real’ and immediate problems for people, person by person, area by area, service by service. Identifying an enemy is not enough.

5)     Oppose efforts to separate individuals from the society that nurtures them.
As with much else, opinion is polarised about the intended and unintended consequences of personalisation on relationships between individuals using self-directed support, other people close to them, and the communities and societies in which they live. The benign view is that personalisation can liberate people from constraining systems of support that are far from nurturing, with people then able to use their resources to develop nurturing and supportive social networks stretching beyond the reach of services and to reconnect more meaningfully with their family, friends and local communities. The malign view is that personalisation atomises the person’s social world, separating them from much-needed support, pitting individuals against their families and leaving them isolated and alone within communities that are at best indifferent.

In terms of personalisation, Foucault’s fifth dictum strongly emphasises the importance of connectedness and ensuring that people’s social networks, lives and communities are genuinely nurturing. For the personalisation project, it is vital to work on these broader aspects of social connectedness and communities which stretch far beyond mechanisms of funding and service provision for individuals and embrace the importance of the collective and belonging in people’s lives.

6)     Preserve the right of self-determination and resist efforts to control “who we are”.
Self-determination is clearly at the centre of the personalisation project, but the terms self-determination, choice and control are often used interchangeably, and there are heated debates about how much choice and control is possible and/or desirable for various groups of people potentially making use of personalised support. Without getting into a long definitional discussion, for me self-determination is the fundamental idea, with the simple principle that people should be the active agents in determining the course of their own lives.

Being self-determined does not necessarily mean having to make choices over every aspect of your life – you may decide to cede control over certain areas of life, for example, with the proviso that you can set the limits of this and take back control when you wish. It also does not mean living a life without being cared for – at various times in our lives we all need to be cared for, but there are other times when we want support or liberation rather than care.

With its conflation of choice and control (and less mention of self-determination), there is a widespread perception that ‘real’ personalisation means in essence supported direct payments, with the person having to act as employer and co-ordinator of their support. A truly personalised approach would have no such assumptions, with people being able to determine at what level they want to have control, the terms under which control is being ceded to others, and when they can take control back – all of which may change at different times in the person’s life.

Foucault’s sixth dictum suggests that it is vital that the personalisation project keeps its eyes firmly on the ultimate prize of self-determination, and that personalisation mechanisms are designed and evaluated with this ultimate aim in mind.

A (non) answer to the question?
Taken together, Foucault’s six dictums suggest a set of strategies needed for personalisation to negotiate its way through existing power structures to become a meaningful reality:
1)  Embed personalisation as part of broader international movements towards self-determination for all citizens.
2) Stay close to the lives of people involved in the personalisation endeavour, documenting and understanding how personalisation works (and doesn’t work), and using this understanding to improve how personalisation works.
3)  Use all forms of knowledge to improve our collective understanding of what is happening, rather than privileging any form of knowledge or engaging in needlessly adversarial debate about what counts as ‘evidence’.
4)  Rather than trying to identify ‘enemies’ to the achievement of self-determination for all citizens, work together to understand the systemic constraints and facilitators to achieving self-determination in specific circumstances  and use these to build better ways of achieving self-determination from the ground up.
5) Ensure that the maintenance and development of people’s social networks and the promotion of nurturing communities is seen as just as essential as paying attention to funding and service support mechanisms.
6) Keep the aim of self-determination (not necessarily choice) in mind at all times, and design and evaluate personalisation projects against this standard.

So, what is the answer to Martin’s question? I’m not sure that there is a satisfactory answer, and even if there is, I’m not sure how far it would take us in making personalisation a meaningful reality for people. Despite the attraction of the grand theory and the big answer for academics like me, Foucault’s analysis of power suggests that there is no substitute for the hard grind of working through the issues person by person and service by service, and working through them together.

Foucault, M. (1994). The subject and power. In J.Faubion (ed.), Michel Foucault: Power, The Essential Works of Michel Foucault 1954-1984 (pp. 328-348). New York: The New York Press.