A loud crunching sound is about to start reverberating from Britain's public services. After a period of plenty, public spending will grow no quicker than the rest of the economy over the next few years. Complaints from producers and users, barely contained even in the fat years, will become very noisy.
Additional resources have disguised some of the underlying problems with public services, many of which are stuck in an organisational timewarp. We are building more prisons. But they look alarmingly like Strangeways in Manchester, opened a century ago. Run-down schools are being replaced, but too often the replacements merely look like improved versions of their Victorian predecessors.
Instead of imposing yet more targets and performance management, we need a different picture of how public services could be organised. The key to this will be to see service users not as consumers but as participants. Postwar public services were built around a paternalistic ethic of professional control and expertise. The current reforms challenge professional power with an ethic of consumerism and choice, but are overlaid with a heavy dose of top-down managerialism. Instead, reform should start to be guided by an ethic of participation and self-management.
Oddly enough, the best guide to how these new public services might operate is an iconoclastic former Catholic priest and visionary who wrote his best work 30 years ago: Ivan Illich. Illich was a critic of industrial society who, in a series of polemical books in the 1970s, set about the failings of modern institutions and the professionals who organise them: Deschooling Society, Limits to Medicine, Disabling Professions and Tools for Conviviality. He was ahead of his time by being behind the times. His critique of industrialisation harked back to pre-industrial, more communal forms of organisation, in which local, low-technology production met most demand. He also foresaw a post-industrial world, using the language of networks and webs long before the internet.
Illich was born in Vienna in 1926 and grew up in a comfortable home, the son of a civil engineer. He was expelled from Austria in 1941 by the Nazis because of his mother's Jewish ancestry. From then on he became an itinerant intellectual, living with few material possessions. After university in Florence, he studied theology and philosophy at the Gregorian University in Rome, and in 1951 completed a PhD at Salzburg University before going to work as a Catholic priest in Washington Heights, New York, mainly with Puerto Rican immigrants. He went on to hold a university post in Puerto Rico before walking several thousand miles to create the Centre for Intercultural Documentation in Cuernavaca in Mexico. The centre, which Illich described as a "free club for the search of surprise," was closed down by the Catholic hierarchy. By the 1980s, Illich's celebrity was on the wane. He taught freewheeling classes at universities in the US and Germany, and in the early 1990s he was diagnosed with cancer. True to his principles, set out most powerfully in Limits to Medicine, he refused medical treatment administered by doctors, wrote a history of pain and died at his desk in 2002, unknown to a new generation of radicals.
In a golden period of creativity in the mid-1970s, Illich set out his idea for how industrial-era institutions might be superseded and reformed. For Illich, all modern institutions draw from the church and all professions gain legitimacy by becoming a form of priesthood. Illich's argument against the church was that it turned the mutual charity evident in the tale of the good Samaritan into a social machine. The church became a systematic source of care and solace, but at the cost of becoming also a source of power and doctrine, in which the priesthood determined who was holy and who damned. Illich's argument was that this perversion, in which care becomes power, eventually affects all institutions and all caring professions: doctors, teachers, social workers and so on.
The triumph of modern welfare capitalism, according to Illich, was the creation of public service institutions—education, health, policing—on a vast scale where they had once been limited to serving just a few. These universal systems aspire to deliver services that are fair and reliable. Yet that in turn requires codes, protocols and procedures, which often make them dehumanising. Dominant professions do not just provide services for people in need, they define what we need. They infiltrate how we think: even though most improvements in health have come from changes in lifestyle—the way we work and eat—in the public imagination, health is indelibly associated with doctors and hospitals, men and women in white coats.
Professional institutions can all too easily become part of the problem they are designed to solve. A hospital that provides a cure for a specific medical condition—an elderly person's broken hip—can quickly disorient a patient as they are passed around doctors and wards. They may emerge with a cured hip but their self-confidence shattered. Similarly, the school system is meant to create opportunity and advancement. Yet any system of ranking is bound to produce failures as much as successes. Indeed, far from encouraging people to learn, formal school trains many people to turn off. School creates the impression that learning is something we do only in special places, at special times in our lives, with the help of special people: accredited teachers. Education is seen as unworldly; to learn is to be cut off from the day-to-day world. By extension, that world cannot be about learning. Education is not seen as a personal project of self-development, but rather a process of certification to show that you have learned what the system expects.
The rise of professional power is mirrored by a loss of individual responsibility. We become cases to be processed by the system rather than participants. Nor does employing more professionals guarantee satisfaction—as the NHS illustrates. Much of the doubling of health spending since 1997 has gone on employing more nurses and doctors. The 2002 Wanless review of the future of the NHS, commissioned by the treasury, suggested that on current trends, health spending would have to double again in the next 20 years to keep pace with demand. That is inconceivable.
A health system based on hospitals is working efficiently when the beds are full as much of the time as possible. Yet a healthy society is one in which people do not need to go to hospital. The hospital-focused health system emerged in response to the contagious and acute diseases born by urbanisation and industrialisation in the 19th century. The aim was to provide a place where trained people—doctors and nurses—could repair people who were ill, a bit like a garage repairs a broken car. Now this system of diagnosis, prescription and monitoring has to face a challenge for which it was not designed: an epidemic of chronic disease in a society in which people live far longer.
In Britain, 45 per cent of the adult population have one or more long-standing medical conditions. Among those over 75, the fastest growing group of the population, the figure is 75 per cent. Many long-term conditions, such as diabetes, can be prevented or dealt with by intelligent self-management. But a health system in which expertise is kept inside hospitals does not allow us to diagnose diabetes early enough. Nearly half of diabetes cases in men are not diagnosed until it is too late. People become dependent upon regular insulin injections, which involves repeat visits to the doctor and difficult changes to diet and lifestyle—and the hospital system is clogged up dealing with diabetes at an estimated cost of £5m a day.
For Illich, professionalised public institutions are nightmares forged out of good intentions. Professions that serve us also disable us. As the philosopher Charles Taylor puts it in the foreword to The Rivers North of the Future, a collection of Illich's last writings: "Ours is a civilisation conceived to relieve suffering and enhance human wellbeing on a universal scale, unprecedented in human history… Yet we also feel that the very systems can imprison us in forms that turn alien and dehumanising."
It is not hard to parody the Illich critique. Some of his ideas for the reinvention of pre-industrial forms of family life do seem dotty. His ideas for deschooling society make more sense for adults and older children than, say, for five year olds learning to read and write. And the self-help movement Illich inspired is often the embodiment of crankiness. But his ideas do chime with many aspects of the internet age.
In Deschooling Society, first published in Britain in 1971, Illich provided some principles for how a more "convivial" education system would work. One idea was to provide all those who wanted to learn with access to resources at any time—in factories, offices, museums and libraries as well as schools. Another was to make it easy for those who want to share knowledge to connect with those who want to learn through skills exchanges. In 1971, that sounded far-fetched. In the era of Wikipedia, eBay and MySpace, it sounds like the conventional wisdom of online social networks. (The social entrepreneur, Paul Miller, is about to put Illich's ideas into action with his online School of Everything, backed by the Young Foundation, which brings together people who have a skill to teach—such as how to use the Sibelius music software programme—with those who want to learn.) Illich's proposals yield a set of useful principles for post-industrial public services which will be dealing with citizens brought up with MySpace and Google.
Modern society trains us to be workers and consumers. Post-industrial institutions should train us for self-management and self-assessment. The modern, professional state spends massive sums on assessing need; perhaps a third of the social care budget goes on assessment. Professionals assess what we need, whether we are entitled to state support and then determine how that should be delivered. Then more professionals, in the form of inspectors, come along to check it has been done properly. We need much more emphasis on intelligent self-assessment and self-evaluation. This is already the linchpin of the tax system and should play a greater role in education and health. Experiments with self-assessment in social care have found that people do not generally over-claim benefits, and are more likely to think about addressing their needs without turning to the state.
As an example, consider the case of a blood-testing service in north London, which has 5,000 patients taking drugs to reduce the risk of clotting. The patients have weekly blood tests, which are administered by nurses and GPs and sent to a central unit for assessment. The unit writes to anyone who needs to change their dosage; if it is urgent they call them on the phone. The system works efficiently: tests are done by 11am and the results are back by 1.30pm.
But in Germany, the patients do this all themselves with a small machine that costs about £400. They do the test whenever they like. They analyse the results and change their dosage accordingly. In north London, only ten of the 5,000 patients use this machine. The unit employs scores of nurses to do tests which could easily be done by the patients themselves if they had the tools, the skills and the self-confidence.
To make that kind of shift possible, public services will have to promote cultural change—motivating people to look after themselves better, not just delivering a service. Similarly, motivating children to want to continue exploring and learning should be one of the chief aims of the education system. In future, professionals should act as persuaders, counsellors and campaigners; as well as delivering a service, they should encourage people to acquire the skills to help themselves. In Limits to Medicine, Illich described health as a personal task: "Success in this personal task is in large part the result of the self-awareness, self-discipline and inner resources by which each person regulates his own daily rhythm and actions… The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed among the total population."
In a world of participatory public services, professionals would still be the most knowledgeable players in any given field, but they would find themselves operating alongside other sources of knowledge. Enlightened professionals know that their jobs are made easier if they relinquish their claim to a monopoly on knowledge and encourage people to turn to other reliable sources. Thanks to the internet, people will increasingly find their way to the sources of news and information they trust. Professional monopolies on knowledge, painstakingly established in the 20th century, will erode rapidly in the 21st.
The rise of mass peer-to-peer systems for sifting information has enormous potential for the public sector. At Lipson Community College in Plymouth, for example, the headteacher Steve Baker has created a semi-formal system of "lead-learners": children who are ahead in a subject mentor those lagging behind. By turning a small number of the pupils into para-teachers, Baker has multiplied his resources. This is the economic logic of computer games applied to education. Games such as The Sims and Second Life increasingly rely on the players creating much of the action themselves. A computer game with 1m players only needs 1 per cent of them to be player-developers and it will have an unpaid development workforce of 10,000 players feeding back content to enrich the game. Imagine an education system that did that.
Illich mainly wrote before the advent of the personal computer, the internet and the mobile phone. In later life he was no great fan of them. Yet they are examples of the vernacular tools he celebrated in Tools for Conviviality that allow people to collaborate and communicate, in contrast to the complex tools that only professionals can understand. We have only just begun to tap their potential. Kent county council is starting trials of home-based sensors to allow remote monitoring of the movements and health of elderly people, which should allow more to remain in their own homes. In South Korea there is a mobile phone that allows diabetics to check their blood sugar levels and communicate the results to a doctor.
But service users need access to money as well as tools. Last autumn I spent an afternoon in Wigan with a group of parents participating in the department of health's In Control pilots, which provide individualised budgets to families caring for young people with learning disabilities. The parents said that as consumers of public services, they tended to complain to get things changed; they were often at odds with service providers and rarely shared ideas and resources among themselves. Once they became budget-holders, they started to look for ways to make the money go further, working more collaboratively with their care workers and with one another.
It is implausible to hope that public services could be reformed, in one bound, to adopt this approach. Nor are these ideas appropriate to every aspect of public services. People in need of urgent surgery do not generally want to be participants in the process: they want a good service, delivered by professionals. Sometimes the ethic of self-help can be abused to get us, the users, to do more of the work ourselves.
The point is that the range of ways we can create public goods is expanding. Schools and hospitals will continue to exist, but more learning and healthcare will be created informally and at home. People will want to be consumers some of the time, participants at other times. And politics is moving in Illich's direction. The government's social care white paper, published a year ago, foreshadows a shift towards individualised budgets. In health, the Expert Patients Programme seeks to mobilise patients to help one another. David Cameron's embrace of the social enterprise sector as saviours of public services is based on qualities that Illich would recognise.
Ivan Illich's genius was to realise, 30 years ago, that this would be not just desirable but would become a necessity. A tax-funded public sector built around passive consumers cannot hope to keep meeting people's rising expectations for tailored services. The only way to personalise services to different needs, on a grand scale and at affordable cost, is to motivate and equip the users to become players, not spectators. Imagine an education system built around the participatory principles of Wikipedia, or a social care system that was as simple to take part in as eBay. In future we will need public services produced by the masses, not just for the masses.
