Human Services and the Caring Society
Human Services and
the Caring Society
There are two obvious ways in which the question of sustainability impinges on the issue of human services. The first has to do with political economy - the political and economic conditions that determine the role of the state vis-à-vis the provision of social care to its citizens. The second has to do with the character and content of social care itself. The two are intimately connected, and changes in one have profound implications for the other.
In Canada and the industrialized north generally, social care systems that have taken a century to build up have been deeply damaged by three decades of government retrenchment, neglect, and the catastrophic effects of free market ideas on public services. These systems constitute the complex fabric of publicly funded safety nets, from universal health care to unemployment insurance and services to the handicapped, that have been needed to offset the market failures in human services that are endemic to a capitalist system. How civil society in general, and the co-op movement in particular, have responded to the effects of these free market ideas has in turn placed a spotlight on how the concept of sustainability, traditionally connected to the carrying capacity of environmental systems, also relates to the functioning of systems for social care.
But there are challenges to transposing the traditional language of sustainability to the operations of social care systems. One obvious difficulty is related to the question of growth. Another relates to the issue of consumption. In the context of economic and commercial activity that depends on the depletion of natural resources, unlimited growth and consumption are negative factors that are by definition unsustainable. This is not the case in the field of social care and many operations of the social economy. Unlike the capital economy, which depletes the natural and social capital upon which it rests, the social economy is characterized by operations that expand and replenish the social capital that sustains it. The production and consumption of human services is not the same as the production and consumption of material goods. How then, do we understand the question of sustainability with respect to human services, in particular social care? This is one question I address in this chapter.
A second question relates to the degree to which different models for the provision of social care embody strong or weak implications for the transformation and strengthening of the social economy and of social care itself. In this framework, strong social economy approaches entail fundamental structural and institutional change, increased scale, the creation of deeper and more extensive social networks, greater scope for capacity building - both for organizations and individuals - and a viable alternative that challenges existing regulatory systems and power relationships. The approach I
outline below, based on the democratization of social care systems and the strengthening of reciprocity, embody an exceedingly strong model of sustainability within the particular context of the social economy and the social and economic principles upon which it rests.
In particular, what I want to explore in this chapter is the question of how the physiology of human services - their organizational and institutional set up - either helps or hinders the production of human services that embody what I would call caring relationships. That is to say, human services that entail actual relationships among persons, as opposed to the interaction that occurs between persons on the one hand and impersonal systems on the other. It is from this perspective that I interpret the notion of sustainability with respect to human services - the capacity of human service models not only to provide social care but to do so in a manner that both recognizes and promotes the nature of care as an exchange of human relations. This perspective draws in my own interest in the transformative role of democracy in human services and raises fundamental questions concerning human dignity and the interplays of power.
Let me begin with a story.
In the winter of 2008, in the small town of Trail in the BC interior, Annie Albo lay dying with congestive heart failure in the Kootenay Boundary Region Hospital. She was ninety-one years old. Her husband Al, aged ninety-six, was also in the hospital - sick and exhausted from the worry and strain of caring for his wife. They had been married for seventy years.
One day Annie was wheeled into her husband's room and told to say goodbye. She was being transferred to a nursing home in Grand Forks 100 miles away. Hospital staff had already strapped Annie to a gurney and so she was not able to embrace her husband in the few moments before they took her away. They said their goodbyes. Annie Albo died alone two days later on February 19, 2008. Al died thirteen days after that.
When the newspapers broke the story a wave of outrage swept the province. Angry letters to the editor, withering television coverage, and uproar in the BC Legislature wrung an apology from the Minister of Health and a promise to examine how such a heartless decision could be made. Nurses working at the hospital organized a petition calling for a public inquiry. According to Margaret Kempston, a registered nurse who worked at the hospital, the Albos' treatment was "horrible and disgusting" but she added that spousal separation "happens all the time". The final injury came to light when a government official confirmed that Trail's single palliative bed was in fact available when Annie Albo was separated from her husband and forced out of the hospital despite the frantic objections of
her family. During the course of the examination concerning the conditions leading to the decision, senior managers at the Regional Health Authority refused to answer any questions saying flatly that proper procedures had been followed. In the end, no one was found at fault, no accountability was forthcoming, no disciplinary action was taken. Nothing changed.
This heartbreaking story illustrates perfectly the tragic consequences and needless suffering caused by a system of human services in dysfunction. Countless stories could be told of other seniors and other families who have endured similar distress and indignity in communities across Canada, across the United States, indeed everywhere patients are powerless to influence bureaucracies that serve institutional interests as opposed to the interests of those they are meant to help. The story of Annie and Al Albo touched a raw nerve across the province. And it was not only the empathy and fellow feeling that prompted the outpouring of anger. It is also the unsettling question that the story raises in the minds of each of us: "could this happen to me?"
Stories documenting the neglect and abuse of seniors have been a staple element in Canada's headlines and news hours for many years. They are depressingly familiar and just as shocking today as they were thirty years ago. What receives less attention is the pervasive anxiety and silent struggle that millions of seniors face daily as they contend with the
challenges of aging with few supports at home, in their communities, or from government. These same fears of isolation, maltreatment, neglect, have remained a constant presence in the lives of the vulnerable, whether they be people living with disabilities or those whose life's fortunes have left them stranded at society's margins. They have reason to worry. Social care systems have been unraveling steadily over the last twenty years. The current economic crisis and the culture of accelerating cutbacks have only deepened the worry.
Historically, the rise of social care in the advanced capitalist societies is inseparable from the advent of democracy, which in turn became possible only with the rise of an organized working class. This is understandable. A prime cause behind the struggle for democracy in the west was to establish a political system capable of distributing to the majority a share of the material security and prosperity that was the privilege of elites. This only comes with a commensurate distribution of political power. And so progressive social policy - the broad distribution of material security through public means - is a factor of democracy. Democracy is essential for the preservation of human services and the protection of the human and social dimension of social care itself.
The character of social care - the nature of its content, its manner of operation, and the distribution of its benefits - has remained relatively unchanged since the great wave of social reform was enacted after the end of World War II. It was at this time that the universal systems of social security, health insurance, family benefits, and public welfare were established. And while it is true that the nature and extent of these social care systems varied greatly from one country to the next, and especially between northern Europe and America, they shared essential common features - in particular the rising importance of government as the provider of social care. But almost all the social policy reforms in Europe and North America since then have been centered on matters of redistribution - extending the coverage of social welfare systems to larger segments of the population. The actual delivery of these services - the fundamental character of the relation between the state and the citizen - remained relatively unchanged until the introduction of free market ideas in public policy in the 1980s. Until then, publicly funded social programs were delivered almost exclusively by the state through centralized bureaucracies.
To be sure, these vast delivery systems succeeded in distributing benefits to unprecedented numbers of people. The quality of life for the large majority of people improved dramatically - greater than at any previous period of history. Centralized bureaucracies were deemed essential for systems in which universal coverage required regulation, standardization of services, and equality of access. Their moral foundation however, was based on notions of charity - the social responsibility of the state to care for its members. But it was a profoundly paternalistic system in which the state provided and the citizen received. This is the nature of charity. The essential character of this disempowering, and ultimately belittling, system was not to be altered until the 1980s when, ironically, the state monopoly over social care was called into question by the adoption of free market principles in the public services by Margaret Thatcher. This shift in the presumptive role of the state by the embrace of the free market cracked a centuries-old mould that had fixed the citizen as a powerless dependent of the state in matters of social care. The fact that citizens contributed to the cost of these services through their taxes had little effect on the powerlessness that they often experienced when actually using these services, particularly social welfare which carried with it the additional indignity of social stigma. It was a model whose antecedents extend back to the Poor Laws of England that stripped the poor and the weak of their autonomy and social identity. And just as the adoption of utilitarian, free market ideas dissolved the relations between the commercial economy
and society at the dawn of the industrial age, so too has the adoption of these same ideas threatened to destroy the social content of care in the public economy.
Today, social care has been commodified. The de-socializing dynamics of the Industrial Revolution that were, at least in theory, contained within the market economy have now reached deep into the public systems that were once the preserve of the state. The colonization of the public domain by commercial interests in the late 20th century is in some ways analogous to the enclosure of the commons in the 18th century. What were once public goods in the form of universally accessible human services have been steadily transformed into commercial goods accessible only to those that can afford to pay for them. As a result, a number of questions arise. Will civil society find the means to reclaim the social and collective foundations of the public systems that are being abandoned by government and annexed by capital? In an era where free market ideas and the influence of capital reign supreme within government, can the state be trusted with public welfare? If not - and this is not merely hypothetical - what is the alternative? And finally, can social care be humanized? The sustainability of human services as exchanges of caring relationships is predicated on these questions.
In Canada, as in much of the industrialized west, most of the debate on the changing role of government has centered on government's retreat from the provision of public services, largely as a response to the deficits of the '80s and '90s and the rise of the view that the private sector can do better. But changes in social policy and the delivery of social care have also been fuelled by widespread public discontent with traditional delivery systems. People were fed up with the paternalism, inflexibility, and dehumanizing attributes of state bureaucracies. The story of Annie and Al Albo recounted at the beginning of this chapter had become a pattern all too familiar for far too many people. Combined with the burgeoning public deficits, this provided a fertile context for the rethinking of public services.
When universal social care systems were first established at the beginning of the last century, first in Western and Northern Europe and then later in North America, social, cultural, and economic conditions were far different from what was to evolve in the wake of the unprecedented material prosperity generated by capitalism. Throughout most of the 1900s, large portions of western society were still an accident or a sickness away from total ruin. Basic social security, health care, worker compensation, these programs were designed to provide a basic standard of care for large classes of people. It was an era marked by a mechanistic industrial paradigm, an age of assembly line automation that paved the way for the service based consumer society that has since come to replace it.
But this transition to a post-scarcity society has brought its own attitudes and expectations along with it. Chief among these is the accelerating individuation of society — the strange rise of the individual as someone who is defined solely by what he or she buys and the construction of personal identity as an extension of market forces. Fuelled by the relentless message of the free market, this has made choice in the marketplace a criterion of personal freedom and a symbol for consumer culture as a whole. Previously, in the mass industrial age, basic health care and universal social security reflected a model of social care that was geared to large classes of people who lacked these necessities. Social needs were generalized. In the post-scarcity era, in the fantasy age of unlimited personal consumption, needs have become specific and concrete, reflecting the precise needs and preferences of individuals, not classes. With society awash in material goods people now expect that social goods and human services will also recognize and respond to them as individuals. Their growing failure to do so provides one means of understanding a possible new future for civil society generally and co-operatives in particular.
The very notion of standardized systems of care that can be applied to all, regardless of personal preferences, has become something of an anachronism. And although the reaction against universalism is rooted in the dubious belief that basic needs have now been addressed, a belief that is willing to overlook the dire conditions of many who still struggle in poverty or barely survive on social assistance, yet it is a point of view that has become characteristic of the consumer age (or at least that segment of society that has the money to pay for alternatives, and is not prepared to wait in line). This is especially true with those public goods that are amenable to personal preferences, and most especially, to their improvement in quality by the expenditure of disposable income, for example health care, home care, services to the disabled, and public education. This shift in social attitudes, combined with the inability - or unwillingness - of the state to respond to the change in public expectations, has been a key factor in opening the way for the commercialization of social care. There is a growing market for it. Another factor was the failure of those forces that believed in universal public care to understand this change, to acknowledge its meaning and implications, and to provide progressive responses that were capable of addressing it.
What eventually arose was a twin movement: a push for more pluralistic and private models of care on the one hand - a continuation of the free market logic - and a contrary movement toward non-commercial, social economy solutions on the other. Both approaches call for more pluralism in how care is delivered and more choice on the part of the individual. They differ radically on how this should be achieved, and this in turn derives from profound differences in the perception of what social care is.
The privatization of social care is the familiar route of the free market approach. The socialization of care on the other hand is less well known and less documented. The fact that it is also less lucrative for private interests goes a long way to explain why so little attention has been paid to it. The other reason is that for two decades a relentless campaign to discredit government, and the very notion of public services was conducted through all the available channels of the media and the academy by the think tanks and private sector promoters that championed the privatization of public services. The clamour for privatization - particularly in health care - has not subsided. There is simply too much money to be made. Despite this, and despite the growing demand for individualized care, public opposition to privatization of universal systems has remained strong. But something is changing nevertheless. A new interest has arisen in the role of civil society with respect to public welfare and social care.
Over the last ten to fifteen years, the rise of social co-ops and other forms of social enterprise has gained considerable attention since the glow of privatized care has lost some of its original lustre. In Canada, the failures of privatization in areas such as home care and long-term care were widely reported throughout the 1990s. The current crisis of the free market model has also undermined calls for its extension in the public sector. (With the recent collapse of the financial and stock markets for example, how many would listen now to proposals for the privatization of social security?) The emergence of social enterprise as a new, hybrid form of social care has been met with growing interest. In the co-operative sector, the rise of social co-ops has been the most significant change to occur in the movement in thirty years. These are co-operatives whose purpose is the provision of social care, not only to their own members but also to the community as a whole. Their primary areas of activity have focused on services to marginalized populations, and to society's most vulnerable groups. These developments signal a change in attitudes toward the market on the one hand and the role of government and the public sector on the other. Privatization is not the only way the market can be used to reform social care. There is a social alternative that reflects a shifting perception of how civil society must now relate to changing times.
The term "civil society" has now entered - or more accurately re-entered - the vocabulary of common political discourse. It is a very ancient idea with roots in the political and moral philosophy of the ancient Greeks and the democratic society in which it was first conceived. The stress on the moral life that was a central part of Greek philosophy was always bound up in the concept of civic duty and the pursuit of the just society.For Plato, the ideal state was one in which people dedicate themselves to the common good, practice civic virtues of wisdom, courage, moderation and justice, and perform the social and occupational role to which they were best suited. Aristotle in turn, held that the "polis" - the citystate - was an "association of associations" and the social reality that made political life possible. For these thinkers, there was no distinction between state and society and the idea of civil society as a political concept was profoundly influenced by the democratic institutions of Athens. It was made possible by the fact that individuals were not mere subjects of an absolute power. They were independent actors with the freedom to form horizontal bonds of mutual interest with others and to act in pursuit of this common interest. This was the essence of citizenship. Politics in the modern sense became possible. This link between civil society and democracy was to remain a defining feature of the term.
In turn, there is a sub sector of civil society that is composed of those activities carried out by organizations that provide a vast range of goods and services through collaboration - by people working together to realize mutual, and collective, goals. It is this economic dimension of civil society that comprises the social economy.
With the rise of interest in civil society and the social economy, the market view of society as composed of two sectors - the private and the public - is once again being challenged. From the start, the notion of social economy was a reaction against the narrow reading of economics as a dimension divorced from society. The social economy entailed an enlargement of classical economics to include the social relations that accompany and underlie the creation and distribution of wealth and to situate economic behaviour within the wider compass of social reality. This is the larger frame in which the social economy has its original meaning.
Current efforts to highlight civil society and the social economy as countervailing forces to the market view are a continuation of the historical struggle to reclaim the social dimension of economics. For both these conceptions - civil society and social economy - the notion of reciprocity is fundamental. It is also essential for understanding the means by which a new view of social care - a civil view - might be developed as a more humane alternative to current systems. And it is in this sense that we might glimpse what it means to move from the paradigm of the corporatist welfare state to that of a caring society. What this means and how it is being realized in the context of human services and the changing role of the state is where we now turn our attention.
Reciprocity is the social mechanism that makes associational life possible. It is the foundation of social life. In its elements, reciprocity is a system of voluntary exchange between individuals based on the understanding that the giving of a favour by one will in future be reciprocated either to the giver or to someone else. A simple example is the loan of a lawn mower by one neighbour - call him Frank, to another - say, Fred. Frank makes the loan on the assumption that at some later date Fred will return the favour. If Fred does not, the basis of reciprocity falls apart. No more loaning of the lawnmower to Fred. Moreover Fred's non-reciprocity, if it continues, becomes reputational. Others will stop extending favours to Fred also. So willingness to reciprocate is a basic signal of the sociability of an individual. Taken to an extreme, the complete unwillingness of an individual to reciprocate is tantamount to severing the bonds between themselves and other people. Reciprocity is thus a social relation that contains within itself potent emotional and even spiritual dimensions. These elements account for an entirely different set of motivations within individuals than behaviour in the classical sense of "maximizing one's utility" as a consumer.
Reciprocity animates a vast range of economic activities that rest on the sharing and reinforcement of attitudes and values that are interpersonal and constitute essential bonds between the individual and the human community. When reciprocity finds economic expression in the exchange of goods and services to people and communities it is the social economy that results. Examples range from the provision of burial services through the creation of friendly societies in the 1800s to the promotion of neighborhood safety through organizations like Neighborhood Watch today.
What is exchanged in reciprocal transactions are not merely particular goods, services and favours, but more fundamentally the expression of good will and the assurance that one is prepared to help others. It is the foundation of trust. Consequently, the practice of reciprocity has profound social ramifications and entails a clear moral element. Reciprocity is a key for understanding how the institutions of society work. But it is also an economic principle with wholly distinct characteristics that embody social as opposed to merely commercial attributes. For one thing, the use of reciprocity increases both its value and the social capital on which it rests. Each instance of reciprocity strengthens the bonds of trust and mutuality that make it possible. An increase in the number and operations of social economy organizations like co-operatives and community service organizations raises the capacity of a community to care for its members. For the provision of humane systems of care, this is the sustainability issue that truly matters.
Finally, reciprocity is egalitarian - when it operates it presupposes a direct relationship of equality between the individuals involved. It is very different from altruism where the giver may have no relation to the receiver and where there is a clear asymmetry of power, as is the case with charity. In the matter of social care this has profound implications.
The rise of social co-operatives represents a new frontier in the shifting boundaries of public, private, and commercial spheres. Pioneered in Italy during the 1980s, social co-ops embody the collectivist and co-operative traditions of the past along with a new focus on individual choice and the use of market forces that until now have been hallmarks of neo-liberal approaches to social policy. The composite of these elements make social co-ops a kind of social experiment that places civil society at the forefront of social service reform. These co-ops are inventing models of care that embody the strengths and values of civil society as an alternative to both state and market systems. In the process, they are forging new roles for civil society and government. And while the debate in Italy concerning the role of the state has raged as it has in all the western democracies, the practical outcomes within Italy have been far more interesting as indicators of where the future of social policy reform may ultimately lie.
In Italy, there are now 7,000 social co-operatives providing social services throughout the country. Social co-ops employ 160,000 individuals, of whom 15,000 are disadvantaged workers. This represents fully 23 percent of the non-profit sector's total paid labour force, even though they represent only 2 percent of non-profit organizations. Today, social co-ops are a central aspect of Italy's social services system. In the city of Bologna, 87% of the city's social services are provided through municipal contracts with social co-ops.
As described in the legislation, social co-ops have as their purpose "to pursue the general community interest in promoting human concerns and the integration of citizens." In this sense, social co-operatives are recognized as having goals that promote benefits to the community and its citizens, rather than maximizing benefits solely to co-op members. Italian legislation also acknowledges the affinity between public bodies such as municipalities and health boards with social co-ops for the promotion of public welfare and emphasizes the possibility of collaboration between them. In consequence, there has grown an important symbiotic relationship between these co-ops and the municipal bodies that are primarily responsible for contracting their services.
Since their establishment, social co-ops in Italy have resulted in improved access and a net increase in the variety and quality of social care. This increase has not been at the expense of civil service jobs, which was a major concern of the public sector unions. Instead, the public services have been able to concentrate on areas where state regulation, oversight, and centralized information and distribution can benefit the system. Social co-ops focus on the front lines of care where service design and ships between caregivers and users are paramount in determining the quality of care that is received. Personal care to the elderly and the treatment of people with addictions are two examples. In addition, the relative cost of care in areas where social co-ops have been operating has declined while the quality of care has improved. Job satisfaction among employees working in social co-ops is also higher than that reported in either the public or private sectors, despite the fact that wage rates are generally lower. Why is this so?
The reasons flow from the nature of social care itself and the ways in which co-op models require caregivers and users to make explicit and reinforce the human relations that underlie care. The principles of reciprocity, equality, and accountability are inalienable qualities of humane care. They are also organizational attributes of co-operative organizations. They are not attributes of either state or private, for-profit systems.
There are three compelling reasons for the promotion of co-operative models for the delivery of social care. The first has to do with the nature of social care and the kind of models that are best suited to deliver that care. This concerns the question of relational goods. The second reason concerns the relation of organizational structure to service design, delivery, and efficiency. The third reason is the need to humanize care through the socialization of its content and its manner of operation. The democratization of care is essential to this.
The "discovery" of relational goods is one of the truly paradigm-shifting developments in recent economic analysis. Unlike conventional goods, relational goods cannot be enjoyed by an individual alone but only jointly with others. They are like a specific kind of public good in that they are anti-rival - their nature requires that they be shared. As a consequence, participation in their consumption actually creates an additional benefit to others and increases the value of the good itself. Examples include the collective joy of an audience experiencing a musical performance, the generalized laughter at a comic film, or the surge of energy that explodes when one's team scores a goal in a stadium. The more people enjoy a relational good the greater its utility! When Canadians gathered in their thousands in bars and living rooms and on street corners to watch Canada win Olympic gold in men's hockey in 2010, the electricity that flowed right across the nation was relational joy on an epic level. On a more intimate level, relational goods acquire value through sincerity, or genuineness - they cannot be bought or sold. Friendship and caring are relational goods and they are their own reward. They are things whose sale would immediately destroy their worth.
In human services, relational goods are services to persons that are characterized by the exchange of human relations. Because in relational goods the quality of the personal relationship lies at the core of what is exchanged between the provider and the recipient they can be optimally produced only by the provider and recipient acting together. Beyond this, relational goods have also been defined as the value of the relationship itself, over and above the particular goods or services that are produced. These qualities apply to the unique nature of social care. Reciprocity, the entering into a relationship of mutual benefit on the basis of equality, is the basis for a type of care where both caregiver and recipient share in the generation of care as a human relation, not as a purchased commodity or a charitable offering. Consider for example, care for a person with a disability. A reciprocal relationship would provide the recipient the means to determine how his or her care would be provided to them; they would have a say in determining when the service would be offered, who their care-giver would be, what the content of the care would be, and how their personal preferences and needs can best be served. Reciprocity in social care entails sharing among equals: of information, of responsibility, and of power. It is the source of dignity for the user, vocational gratification for the caregiver, and mutual accountability for both. It is the mechanism by which a society makes manifest its internal solidarity and the mutual responsibility of its members. Without the democratization of care through the sharing of power and the reordering of relationships on the basis of equality none of this is possible. co-operative structures in which power is shared between provider and user make this possible.
Services such as education, health care, and care for people with disabilities are "social" because they are not merely commercial commodities. They refer to social relations that are wholly different from the exchange of commodities for profit that characterize commercial transactions. This is why the reference to such services as "products" or the recipients of social care as "clients" is so profoundly false. It is the unthinking urge in a market society to commodify a human, and social, relation. Neither state bureaucracies, which depersonalize social service recipients, nor private sector firms, which instrumentalize recipients as a source of profit, can ever be suited to the provision of relational goods.
To be clear, I am not claiming that private sector firms are incapable of attending to the caring aspect of a social service. I am saying that the cultivation of the relational aspect of care, what is in essence its human factor, is not generally in their interest since it means investment in time and therefore money and their objective function is to maximize profits. The same problem of conflicting priorities also serves to undermine private firm investment in employee training and professional development that results in additional reductions in service quality, employment standards, and staff morale. But in both cases - state and for profit delivery - what suffers is the quality of a caring and reciprocal relationship which is at the heart of the service being produced. This shortcoming of conventional delivery systems has actually little to do with the intentions that lie behind these models of social care. What is at issue is the faulty physiology of the structures and the economic principles used to provide care to people. Neither the redistributive economic logic of government nor the commercial exchange logic of the private sector can do justice to the reciprocity principle of social and relational goods.
Organizational form is fundamental to the relationship between the content of social care and the systems that provide it. In state delivered systems, social care is properly perceived as a civic right that should be available to all citizens equally. But equality in service delivery rarely translates into social care that is fair, or appropriate, or responsive to the unique needs of individuals. What is fair for all is often grossly unfair for individuals. Universal access through state systems requires that services be designed for application to large classes of users, not individualized cases. Inflexibility, remoteness, and regimentation of care are a necessary consequence. This is the inevitable dehumanizing and impersonalizing effect of bureaucracy.
All this is well known, both academically and in the lived experience of countless individuals that have had to endure the inefficiencies and indignities of bureaucratic systems. An alternative to both private care and traditional government delivery is inescapable if the public nature of health and social care is to be protected and yet made responsive to people's actual needs and preferences. With the right models reflecting the innate qualities of care as an exchange of relations among people and a public policy that promotes such an approach, the provision of care can be extended throughout society at a local, community level. In addition to radically transforming the provision of care, such an approach has the potential to transform society as well.
Co-op models for the production of health and social services have shown a remarkable capacity to provide new types of care at a cost, and in a manner, that blends the benefits of a public good with the choice and responsiveness usually associated with a private sector service. For example, social co-ops have played a major role in improving both the quality of home care and the working conditions, wages, and professional competence of home care-givers. Another example is the provision of life-skills training and employment to people with intellectual disabilities. In many social co-ops such individuals not only find meaningful employment, they also sit on the board of directors and with support from personal advocates have a say in how the enterprises are run. The reasons for these kinds of improvements stem from the structure of co-operatives as user-owned and operated organizations. Like public services, co-operatives have a mutualistic function -to serve the collective needs of member-owners. In the case of social co-ops, these aims are extended to the community as a whole. But the scale of delivery is much smaller, community based, and unlike government systems the design and delivery of these services rests in the hands of co-op members. The operation of these control rights by members provides the choice with respect to service that is characteristic of the private market.
In the case of health services, co-operatives have pioneered a patient-focused approach to health care that is a direct consequence of user control over the design and delivery of these services. Health co-ops in Canada provide community based care to over 1 million Canadians. In BC, there are now health co-ops operating in Victoria, Port Alberni, Nelson, and Mission with interest growing in other communities as well. They were started to provide communities with the kinds of health services that had either been withdrawn by the Province, or never provided to begin with. Other key human services that are being developed include a funeral care consumer co-op that can offer its members responsive and affordable funeral services without the predatory pricing typical of the funeral industry. Across Canada, there are 39 funeral co-ops with 25 of them located in Quebec. Everywhere they operate, funeral co-ops have been a major influence in keeping the cost of funerals down while providing exemplary service to their members.
In the provision of social care, social co-ops and other forms of social enterprise have increased the range of services available to citizens while simultaneously containing the costs for the provision of these services by the state. In both cases, the co-op model has been most effective when it is developed as a complement, not a substitute, to public services. In those places where social co-ops are most advanced, their proponents advocate strongly for government to continue playing a central role in the funding and regulation of public services.
The case of social co-ops in Italy shows that the multi stakeholder structure of social co-ops is a key factor in the role these co-ops play to lower costs, increase service innovation, address market failures, and respond to the changing needs of individual users. The involvement of stakeholder groups in the production and delivery of services confers advantages that differentiate these co-ops from conventional non-profits, private firms, and government agencies.
Since social co-ops are controlled by a variety of stakeholders, costs are contained because they are not controlled solely by those who receive monetary benefits from the organization - employees in the case of non-profits, or investors in the case of private firms. The control rights exercised by consumers and volunteers moderate the distribution of profit and the rise of costs and so social co-ops can provide services more efficiently. The involvement of consumers and volunteers in the delivery of services also lowers the cost of production.
Moreover, the involvement of multiple stakeholders reduces the traditional asymmetries of information that compromise the efficient delivery of services in non-profits, welfare service models, and private firms. Consumer involvement in particular, increases access to information, spurs innovation in service design, and raises the levels of transparency and accountability in the organization.
Social co-ops are better able to cope with insufficient budgets, which is a key market failure of government services. The combination of public and private funds that are used to capitalize services is a key strategy for distributing costs in a way that subsidizes those who are less able to afford the services. The involvement of multiple stakeholders also limits the monopoly market control of government services and the attendant problems in the ability of users to access services that actually reflect their preferences.
Finally, since social co-ops are not as limited in the distribution of profits as conventional non-profits, they are better equipped to raise capital from members, funders, and other stakeholders. They are also able to provide a limited return on capital to investors and funders. These capital advantages make social co-ops more entrepreneurial and more able to finance innovation in service delivery or the development of new projects. Taken together, these features of the model greatly increase its sustainability not only because they reinforce a humane quality in the kind of social care provided but also because they strengthen the economic basis for its provision.
Social co-ops, like all co-operatives, are defined by the fact that they grant control rights to stakeholders and members. In this sense, they are distinct from other non-profits that are defined essentially by the constraint on distribution of profits. In a co-operative structure, it is the element of member control and ownership of the co-operative that defines both the culture and the operations of the organization. In those social co-ops where the service users are also members, the operation of control rights has the capacity to transform the user from being merely a passive recipient of care - an object of care systems, to being a protagonist in the design and delivery of the care - an active subject in the care relationship. Social care becomes a shared outcome between caregiver and care receiver. This element of personal control is fundamental to the reform of social care systems, particularly for those who are most dependent—people with disabilities, the poor, and the marginalized. The reform of social care, its transformation into a humane system of social relationships, requires at minimum its democratization. This democratizing element is the central reason why co-operative forms of social care represent such a strong instance of sustainable human services - they embody the reciprocal nature of care while transforming the institutional structures that provide it.
Despite the role that social co-ops in Italy have played in social care reform, for the most part, organizations within civil society as a whole have been very reluctant to engage government around the question of remaking social care. For two decades, this role has been controlled by private sector groups in the advancement of their own commercial interests, and - perhaps - as part of a genuinely held belief in the superiority of free market models. What this has meant is that civil society and the political Left generally, has been placed in the position of defending a dysfunctional status quo. Labour in particular, has been unwilling to countenance any move that can be construed as weakening the state role in public services - and by extension - compromising further the jobs of civil servants. In Canada, as elsewhere, the ripping up of collective agreements, the downsizing and loss of thousands of public sector jobs has taken its painful toll. Among its crippling effects is a fortress mentality on the part of organized labour. But the uncomfortable question must still be asked - if labour's interests, in Canada at least, are driven solely by the fact that the bulk of their members and dues payers are in the public sector, how can they be a force for a reform of social care that questions the received role of the state?
On the whole, the posture of the political left and of those segments in civil society that have become active in this issue is defensive - a conservative force in opposition to change. Given the damage done to public services in the name of "reform" over the last two decades this is understandable. But the continuing defense of the state monopoly model is untenable, short sighted, and revealing of serious weaknesses. The short-term interest of labour is one issue. A second is the dependence of many civil society institutions on government. Civil society, despite its formal distinctions from the state, remains a dependent sector - in many ways a client sector of the state.
Too many non-profits, NGOs, and the leadership they employ are kept in operation solely by government funding. For example, more than 50% of the cost for services provided by voluntary non-profit social welfare agencies in the United States is funded through government purchase-of-service arrangements. Government funds account for 65% of the Catholic Charities budget, over 60% of Save the Children and 96% of the funding for Volunteers of America. The same is generally true in Canada. This absence of autonomy has undermined these organizations' capacity to represent, and fight for, the interests of civil society as a sector with its own interests apart from those of the state. At a time when government has all but erased the distinctions between private and public interests, state dependency threatens also civil society's capacity to demand reform of public institutions in
accordance with the values appropriate to those institutions and the public interest. Failure to take full measure of the issues at play and to show leadership on what is perhaps the defining question of pubic policy at the dawn of the 21st century has left the field precisely to those forces least concerned with the public interest.
In a move that should serve as a wake up call for the Left, the case for a civil approach to human services is now being led by conservatives. The Big Society experiment now unfolding in Britain has become a central tenet of the Cameron government even as it slashes public funding for everything from health care and education to public transport and postal services. In the Big Society view, civil society is being invited to take up the challenge for the production of human services and a vast range of government programs using arguments for increased user control, democratic accountability, service flexibility and innovation and the empowerment of citizens and local communities. The intellectual case for this approach has been made by Phillip Blond, a former lecturer in philosophy and theology, who has argued that it is only conservative values that are capable of protecting the social bonds of community that are undermined both by the paternalism of the state and the rampant individualism of liberal ideology. His argument for an alternative to statism on the one hand and privatization on the other has provided intellectual cover to Conservatives who are now cutting public services while mouthing ostensibly progressive values. To do
so, Blond rewrites economic and political theory to deny the role that both socialism and liberalism have played in the development of civil values, including an understanding of social care as a collective responsibility. He also conveniently glosses over the appalling historical record of political conservatism, particularly in Britain, as the primary obstacle to the emergence of public systems of care for the vulnerable.
But the most disturbing question is this: why is it that the civil case for the provision of social care has come from conservatives and the political Right? How is it that once again, the terms of this fundamental debate about social care have been set by those historically least committed to it? Without question, progressive forces have once again been outflanked on a central point of public policy and it is merely a question of time before the same progressive arguments for the reform of public services will be appropriated by the forces of conservatism in Canada and the U.S. Already, the Harper administration in Ottawa is undertaking a wholesale review of the charitable sector, including a rewrite of charity legislation to reflect a more "entrepreneurial" and market driven approach to social giving. In this, it is taking its cues from the Cameron government in Britain. And, as in Britain, those sections of civil society that have historically been most committed to improving social care for the most vulnerable will be deeply skeptical, and for good reason, of the outcomes.
Nevertheless, the sustainability of human services and what I have termed the relational content of care is deeply related to the emergence of new, civil forms of social care that complement public systems. Both forms are necessary. And for those who advocate a more humane alternative to the status quo, it is not enough to demand that civil society play a larger role in the protection of existing social services. What are needed are new modes of social care that embody the attributes of reciprocity, accessibility and accountability if alternative models are to be viable. In this, Blond's diagnosis is correct. But what is lacking is the blend of organizational form and public policy that can combine empowering and socializing delivery models on the one hand with new economic and power sharing relations with the state on the other. What is needed is a new conception of market forces with respect to social care and relational goods. In this context, we can at least thank the British Tories for showing that this is possible, even if the underlying motives are suspect.
Civil society finally has to reflect upon and articulate civil solutions to the challenges of social care in a new era. This entails the liberation of civil society from its subsidiary status to the state - the maturation of the sector as an independent social force - and the creation of a true civil economy for social and relational goods; a social market suited to the unique operations of the social economy. Only in this way will the overwhelming power and influence of the capitalist market be brought into balance with civil values. An autonomous civil economy based on reciprocity and civil values makes possible also the political power necessary to negotiate a new social contract for a new age.
In evaluating the effect on human services of the policies and practices outlined here, there seems little question that the potential impacts with respect to structural change, market-based activity, scale, networking, and challenges to existing regulatory systems and capacity building are profound.
The reconstruction of human services along civil lines entails a deepening of the relations among social economy organizations and a convergence of ideas and practices around a long-term vision for humanizing social care by embedding the practice of reciprocity and expanding democratic control by citizens. For strengthening the social economy and for promoting social care systems that both sustain and enhance the human element of care, a civil model of social care is fundamental. In this sense, the approach outlined here represents an exceptionally strong social economy framework for interpreting the issue of sustainability with respect to human services. A focus on civil systems of social care that activate the key principles of reciprocity and democratic control results in the transformation of human services at a broad institutional level while simultaneously expanding the scale, coherence and capacity of the social economy itself.
The overwhelming challenge that remains is whether the key institutions of civil society and the myriad organizations that compose the social economy can find common cause to advance a vision of social care that is both progressive and transformative. This is key. It is clear that the status quo is not working. And those who set the terms of the debate for change will win the day because as the poet said, "The Times They Are A Changin'. But perhaps not in the way we had hoped. Just look at Britain.