David Brookes recently argued that our view of human nature should have profound implications for how we run public services.
What are those implications? Or, as Americans say, “where’s the beef?”
Over the course of this week I am going to try and sketch out what I think are some of the implications for public services of new insights into human nature. Specifically, I will be looking at the implications of findings on the importance of social networks.
I would really appreciate your feedback on what I write here.
- Do no harm
I think the most obvious and least contentious implication of the importance of social networks is analogous to Mill’s Harm Principle. Wherever possible public services should attempt to ensure that they do not damage people’s social networks. If they do, they should be conscious of what they are doing and have weighed carefully the costs and benefits of such a course of action.
Although this may seem a fairly obvious principle it does immediately raise the question as to whether social networks are good in and of themselves and whether there are optimal arrangements of social networks. I am indebted to Perri 6 for raising these points with me.
I am not arguing that simply having a large number of friends or acquaintances is a good thing or that there is a perfect arrangement of acquaintances that we should aspire to. However, I think there are clear cases where damaging someone’s social networks can have negative affects on people. For example;
We know that loneliness and isolation can be very bad for people. However, those people who are most isolated or lonely are often those who benefit from a large number of public services.
In many cases these public services actually reinforce isolation. This could be through agency care workers that come and go at a bewildering rate or online customer services that are completely impersonal.
Being forced to think about how the bread and butter work of public services can reduce isolation, rather than reinforce it, is one of the most striking challenges to come out of the work on the importance of social networks. This could come through initiatives like TimeBanking, Co-Production or by networking services users, as is done in Southwark Circle.
Governance and participation
For several decades now there has been a cross-party consensus that the users of services should participate in the governance of those services. This can be seen in a range of initiatives from Safer Neighbourhood Teams to tenants sitting on the board of Arms Length Management Organisations for housing stock to Local Involvement Networks for health.
The coalition government have continued this approach, notably encouraging parents to be more involved in the running of schools and giving patients a role in the new health and wellbeing boards.
A social networks perspective throughs up an interesting take on the idea of participation in the governance of public services. One of the strongest reasons for encouraging this type of participation is that service users understand the needs of other services users and are therefore representative of other users, in some sense.
However, a paradox here is that those service users that do participate in this way are often labelled as ‘the usual suspects’ by public officials and their views can be discounted. Worse still, their connections with other service users can be weakened as a result. Partly because they spend so much of their time attending board meetings and the like but more profoundly because they are seen to be part of the system.
The implication is that when public services create space for the participation of service users in governance arrangements they need to ensure that they go out of their way to support these service users to network and remain in contact with as many other service users as is possible.
Disrupting social networks
There are often reasons why government programmes might radically disrupt people’s social networks, for example a transport project, such as a new high speed rail link, or a regeneration project such as the one currently taking place in the Aylesbury estate.
These large infrastructure projects are very difficult to cost. Considerations over land prices, optimism bias from contractors and the availability of finance all need to be weighed up.
It is much harder to put a price on the social networks that are disrupted by such projects. It is also harder to mitigate against the disruption that will be caused. However, I think that one of the conclusions we should draw from insights on the importance of social networks is to be wary of projects that will radically disrupt social networks and take all possible measures to mitigate the damage that might be caused.
I would love to hear your thoughts on what I have written here and whether you think there are other implications for public services.
Three of the most intractable problems in the field of mental health services are stigma; isolation and disempowerment.
Stigma can be partly be combated through educating the public and through marketing campaigns. But there is very little that is better at dispelling stereotypes than direct contact.
Isolation and loneliness can be addressed through neighbourhood activities and institutions that bring people together.
As we recently argued, disempowerment can partly be understood as having a lack of resources in your social network. If you do not know people who can help you to get things done then you are much more likely to feel like you cannot control the forces that act on you. Part of empowering people, therefore, is sustaining and developing their social networks, for example introducing them to people who might be useful to them in the future.
In short, part of the solution to all three of these problems must involve talking about people’s relationships. This can be a tricky subject for mental health professionals and for service users.
I recently chaired a panel discussion around this topic at the One In Four conference.
There was no shortage of at the conference. People were discussing how personal budgets, micro enterprises, co-production and network weaving could all be ways of supporting and developing people’s social networks.
It struck me that this would require a quite different role for the state. Rather than delivering solutions to service users the state would be supporting and sustaining an environment in which people are able to develop their own social networks. If you want a practical example of what this would look like you might have a look at the Southwark Circle project that Participle started.
One of the many reasons why I do not think we are going to see this type of culture change within mental health services is our own ambivalence towards the state. One the one hand there is huge mistrust of the state; we are sceptical on the efficiency of the government (“waste”) and often on the motives of government (e.g. “stealth taxes” or “big brother”). On the other hand there is a strong belief that the government is largely responsible (see this report especially from page 12 onwards) for bringing communities together. This “ambivalence gap” leads to a type of risk adverse paternalism from public services.
Worryingly this means that changing the way public services are delivered means changing ourselves.
A survey from yougov has found that just over a quarter of men say that they would go without human contact for a year for £1 million. Only 1 in 10 women said they would do the same.
That doesn’t mean that they would of course, but it does show something about the differences between the sexes in terms of consciously valuing human contact.
In fact, in general women seemed to be much less impressed by the offer of £1 million, whereas men seemed cavalierly to agree to naked portraits, water-boarding and branding…
Christakis argues that obesity spreads from person to person, like cholera.
People who have lots of social connections are more at risk of obesity just as they are more at risk of cholera. Those in the periphery of the network are less likely to become obese.
This might seem strange to viewers of Channel 4s Britain’s Fattest Man, which followed Paul Mason, a man who is noteworthy for being both obese and having very few friends.
I think Paul’s story tells us a lot about the types of problems we face as a society and give us a glimpse of how reformed public services could better solve these problems.
As the candid consultant observed in the documentary, most of the people he sees who are very overweight have some underlying problems with relationships. In Paul’s case, his main problem was that he did not have any relationships.
Paul’s weight was average as a teenager but then, in quick succession, he broke up with his girlfriend, lost his job and his father died. His mother then became unwell and he moved in with her to be her sole carer.
Faced with this strain he started to eat. You can easily imagine other people in similar circumstances turning to drink or drugs, but Paul turned to food.
He ate so much that he needed to re-mortgage the family home. His sisters promptly disowned him for squandering their inheritance. His mother then died. He was acutely isolated and ill-equipped to deal with this.
He continued to eat. He was eating 20,000 calories a day, 10 times the recommended amount.
Eventually, the public purse started to support him in more and more dramatic ways. He was provided with a carer who supported him for 12 hours a day. He was given money in the form of benefits. He was given special equipment. Eventually, he was brought into hospital for a series of operations to reduce the size of his stomach. He is now of a size where it is possible for him to move around on a specially designed wheelchair, and he receives fewer hours of support.
We might be tempted to argue that the huge cost to the taxpayer (over 100,000 a year in care costs alone, the Daily Mail estimates) do not represent good value for money, we might even be tempted to agree with Paul himself, who is suing the NHS for allowing him to get so overweight.
These are both interesting points. I am reminded of Cacioppos work on loneliness and Smalls work on the role of institutions in building our social networks. I think it would be fair to sum up their arguments by saying that loneliness has a very negative effect on people and that institutions can build peoples social networks through placing obligations on people.
How might this apply to Paul Masons case?
As things currently stand Paul’s isolation was partly remedied by paying a care worker to visit him for 12 hours a day. The medical consultant obviously did not consider it anything to do with him that Paul was isolated. Neither, presumably, did the Job Centre when they assessed him for his benefits.
However, the relationship Paul had with his care worker was not of the type that exists between friends and family. There was nothing reciprocal about it. He was in receipt of her presence as long as the Local Authority deemed him entitled. This type of relationship infantilizes and breeds dependency.
A different approach might have been to require and support Paul, when he first appeared to the authorities as being severely overweight, to undertake activities which might grow his social connections. He could have been moved in the direction of the local timebank or a local sports club that needed volunteers.
At present the rights and responsibilities approach to benefits emphasises the need for applicants to look for work or to attend courses to help them find work. Perhaps it is time to consider other types of responsibility being placed on benefit recipients. This would have the dual advantage of growing individuals social networks and saving the public purse since people will be less likely to need the very expensive downstream treatments such as stomach staples and liposuction.
I recently took part in the London Triathlon with a friend of mine. This fired off a couple of thoughts about communities and community life.
Coincidentally the triathlon was based in the Excel conference centre in East London, just opposite Silvertown. I say coincidentally, because I had, in a previous job, undertaken a review of a housing development in Silvertown.
This was the kind of review which doesn’t get done enough. I looked at how much the housing development had met its original objectives, now that it had been built for over a decade.
Part of the idea behind the development was that placing social housing next to private housing would encourage the social housing tenants to make connections with their wealthier neighbours and, thereby, improve their lot.
What I found was that the residents of the private housing were, overwhelmingly, DINKYS (Double-Income families with No Kids Yet) who liked the convenience which the DLR line offered them and the new build houses. They did not use the local shops, the local schools or the local community centre. Their social networks took them much further afield. They had friends all over London, they worked some distance away and they did not intend to live in the area for very long.
This meant that very few relationships were formed between the social housing tenants and those who lived in private housing. It reminded me of a book about the Reformation which showed how Catholics and Protestants had a completely different way of thinking about the cities they lived in.
Perhaps the original plans were based on a nostalgic idea of community where people would automatically know their neighbours and be in and out of each other’s houses the whole time.
As I was huffing and puffing my way along the triathlon I started thinking about a new initiative called the Good Gym.
As I understand it, people who sign up to the Good Gym are linked with an isolated person who lives in their area (it’s based in Tower Hamlets at the minute, quite near Silvertown actually).
Then, when they go for a jog, they stop off at this person’s house, for a quick drink and chat. This has the dual advantage of encouraging exercise (I know I trained a lot more for the triathlon because I trained with a friend – the peer pressure alone kept me exercising) and widening the social networks of people who are isolated.
Perhaps this is the kind of low cost initiative which was needed for the Silvertown housing development to achieve its objectives.
Finally, as a treat for getting to the end of this blog post here is a video of me finishing the triathlon, holding hands with the friend I trained with!