Valuing what we’ve got

Implicit in the proposal to create a new kind of health and care service is decommissioning at least parts of the current one. It is worth restating that this book should not be read as a charter for cutting state services. Services have already been cut beyond the level at which real suffering is being caused to hundreds of thousands of UK citizens, including the 1.2 million older people who need state support but are denied it (Age UK, 2017). We need all the current investment in public services, and more, if we are to catch back up with the hugely increased demand for support, much less keep pace or overtake it. So we still need most of our current institutions: our hospitals and care homes and prisons, but if the changes in this book reduced demand on them, they might return to something like sustainability. In other words, building a new system is a matter of survival for our traditional services, not a case for their closure.

One of the ways in which we need to change our view of public services is our tendency to think of a building, such as a hospital, as a public service and therefore treat the whole collection of resources in and around that building as one, inviolable public good. A hospital, school, nursing home or community centre is a collection of kinds of resource, which include the buildings, the kit in those buildings, the services based in them, the staff teams and the capacity of the people whom they support. All have value, but their relative values are not all equally recognised within public service hierarchies, which value resources according to the proportion of the overall budget they account for. So the most powerful people in the system manage the largest budgets.

Also contained within and around any building are the relationships between the people who use it and work in it. Those relationships do more to determine the effectiveness of most services and their impact on people's lives, but they are invisible and have no cash value.