Making the connection: Health and adult education

The third Global Report on Adult Learning and Education (GRALE 3), published by the UNESCO Institute for Lifelong Learning in 2016, highlighted the impact of education on health and wellbeing and urged policymakers to strengthen the links between education and health. Adult education, in particular, it reported, had a demonstrable positive impact on:

  • general health, reducing absenteeism at work and in education and enabling people to better fulfil their family and community responsibilities;
  • behaviours and attitudes (e.g. reductions in alcohol consumption and smoking and increased sexual health awareness), stimulating greater personal responsibility for health;
  • life expectancy and an extended period of life without limiting disabilities; and
  • mental health, lowering rates of depression and promoting better coping strategies and greater life satisfaction.

Self-esteem and self-efficacy are other important outcomes of learning, relevant to improved mental health and wellbeing in particular, as highlighted by Cathie Hammond in The wider benefits of Learning: The impact of education on health, family life and social capital (Schuller, Preston, Hammond, Brassett-Grundy and Bynner, 2004). Hammond also reminds us that education and wellbeing need not always have a positive impact on self-esteem and self-efficacy, for example if a student’s experience raises expectations that cannot be met or reinforces negative self-impressions. Nevertheless, the picture overall is an overwhelmingly positive one.

At a societal level, these individual benefits result in increased human capital and more active citizens, a reduction in healthcare costs due to increased use of outpatient care and a decreased use of inpatient care, and a more active, productive, self-reliant population. The benefits are well-evidenced (through the work of the Centre for Research on the Wider Benefits of Learning, for example), yet, in practice, while most countries say they recognise the benefits of adult education to health, few do much to support or promote these benefits, and effective coordination between health and education budgets is rare.

It is increasingly obvious that this needs to change. The cost of healthcare has been a hotly debated topic in the UK in recent weeks, for example, with many questioning whether the NHS funding model is broken and universal, fee healthcare no longer affordable. However, the problems facing the NHS are not unique to the UK’s healthcare funding model. They are typical of all countries where populations are ageing (and, in fact, far from being broken, the direct taxation model remains, according to the King’s Fund, among the most efficient ways to fund healthcare). Nevertheless, with costs rising steeply, something has to give, and endlessly increasing investment in treating illness is not much of a blueprint for the future. With people living and working longer, it is crucially important that countries find ways to coordinate their policies on health, mental health and education, especially adult education.

As GRALE 3 shows, even small investments in education can have large returns for health. Yet in many countries – and certainly in the UK – investment in adult education has been declining. Adult learning is often squeezed out when education budgets are cut and the tendency of policymakers to work in silos makes it difficult to make a persuasive case for using a portion of health spending, however small, to fund adult education. Equally, it is a challenge to convince employers that it is worthwhile investing in staff development opportunities that are not directly related to job performance. Employers are understandably reluctant to invest in something that seems to be of no direct benefit to them and tend to regard it as an unaffordable luxury, but, in fact, organisations such as MerseyTravel and Arriva in the UK, which have adopted such policies, often in collaboration with unions, report real benefits in terms of staff morale, loyalty, retention, absenteeism and the culture of the organisation. Ford’s new campaign to raise mental health awareness in the workplace is another example of a company recognising that worker health is not a peripheral concern but something employers must take seriously and invest in.

One of Sir Alan Tuckett’s innovations as Director of the National Institute of Adult Continuing Education was to introduce a scheme to fund the small-scale learning of all staff – the one condition was that the learning had to have absolutely nothing to do with their day jobs. This was a brilliant idea, which led people in all sorts of different directions – I recall one colleague taking a butchery course, while another took ukulele lessons (later touring with a band). But what was interesting, I think, was the impact this had on people’s sense of wellbeing at work, their feeling of belonging and the intellectual culture of the place. This kind of ‘seriously useless learning’, to borrow Alan’s phrase, can give people a start in a new career, help them cope with depression and other difficulties, improve their self-esteem and confidence (and consequently their relationships with others), reacquaint them with learning after a lengthy absence, and ignite a real passion for learning. And, of course, these benefits ripple out, into people’s families and communities. The scheme was a great example of an organisation living the kind of change it wanted to see in wider society.

Even in times of severe financial constraint, the case for investment in adult education as a means of reducing health costs and supporting the health and wellbeing of populations is strong. However, as GRALE 3 makes clear, it is not only a matter of investment and, in fact, relatively modest increases in spending can have a huge impact here. Equally significant is the coherence of policy-making and the coordination between sectors. Yet, in too many cases, compartmentalisation and poor interdepartmental collaboration limit the positive impact of education on health and wellbeing. Only 20 per cent of respondents to the GRALE 3 survey felt collaboration between health agencies and adult education providers was effective. The 2030 Agenda for Sustainable Development is, in effect, an invitation to this sort of collaboration, as GRALE 3 points out. Its 17 goals are ‘inseparable’, which is to say they cannot be achieved singly but only through considered attention to all and the way in which they interact. It demands that areas usually kept apart in policymaking are brought together and encouraged to talk. There is something here on which policymakers can build.

The truth though is that none of this will happen without far more engagement and proactivity from the wider public, to whom the goals of the 2030 Agenda are largely unknown. Disparities in engagement reflect deeply entrenched inequalities in education and health, which, of course, compound each other. Another key finding of the Centre for Research on the Wider Benefits of Learning was that engagement in adult education courses predicted greater levels of civic and political participation. Countries serious about addressing these inequalities will already be investing in the lifelong and lifewide learning of their citizens, recognising that without intervention the benefits of education for health will tend to coalesce among those who have already benefited the most. The societal and economic benefits are considerable but many countries, I fear, will consider an increase in civic participation to be a cost rather than a benefit. Nevertheless, the cultivation of a culture of lifelong learning is probably the most constructive thing any country struggling with the rising costs associated with an ageing population can do, and it is arguably a precondition for achievement of the 17 Sustainable Development Goals. Certainly, those goals will not be met without the civic and political engagement of citizens.

Some countries are already moving along this road. Others, such as the UK, seem to be moving backwards. The failure to invest in the skills, talents, aspirations and creativity of everyone in society, at every stage of their lives, looks increasingly wrong-headed, given the challenges we now face. Countries need healthy, active, resilient and flexible lifelong learners who are able to adapt and retrain throughout life if they are to be competitive, productive and successful. And people need and deserve the opportunity to realise all they can be, whoever and wherever they are, as a matter of social justice. After a decade or so when many governments, the UK included, have substantially reduced investment in the learning of adults, despite the increased acceptance of the wider benefits of lifelong learning, maybe it is time to change course.

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Politics, democracy and the NHS

In the early 1990s, my grandmother became seriously ill. She had a stroke; caused, it turned out, by a tumour in her brain. One morning she was taken by ambulance to a crowded NHS hospital in Liverpool. No beds were available. She was placed on a trolley in a corridor where she remained, untreated and undiagnosed, for the next eight hours. The tumour, we later discovered, was inoperable, and she died not long after, cared for by family and the excellent MacMillan Nurses.

This was what the NHS was like at the time. Chronically underfunded, under-resourced and terribly stretched, often past breaking point. Stories of people being left on trolleys for hours because of the shortage of beds were common. Nevertheless, things got better. Funding was increased, waiting times improved, and, within a decade, the service was unrecognisable to the one we encountered that day in Liverpool. Of course, the economy was doing well, but it is not always the case that when the economy improves so too do our public services. Most importantly, healthcare became a priority of public policy.

Of course, there remained occasional examples of truly appalling care, notably in Mid-Staffordshire, but these were very much exceptions. Yet while the crisis persisted, many commentators pointed to the NHS’s funding model: Yes, of course, we all love and value the NHS, they explained patiently, we all want it to remain as it is, free to all at the point of care with the same quality of care available no matter what your income, but it just isn’t affordable, I’m afraid. We have to change the funding model. Privately, politicians drew up plans for a private healthcare system in the UK.

Now, once again, the NHS is in crisis. As before, the background is cuts to funding and a lower than average (compared to comparable countries) spend on health and social care as a proportion of GDP. And, as before, the funding model is in question, with commentators pointedly wondering whether it is possible to have an adequately funded system in which access is unrestricted and the level of care universally good. Clearly, funding is a huge challenge. But before we throw away what is truly great about our healthcare system, we need to think hard about what we want it to be, who we want to be, as a society, and what our priorities really are. We should not just talk about the NHS as though it is a closed system, with a discrete funding stream on which decisions made elsewhere don’t impact. We need to think much bigger, taking into account issues such as poverty and wellbeing which place a strain on health services.

I do not want to say that the NHS is perfect or that it could not operate more efficiently and effectively. There are clearly things we could change, such as its focus on treatment rather than prevention. There are major cultural and educational issues too. And we need to be smarter when it comes to promoting active ageing, ensuring, in particular, that older people have opportunities to continue learning (a hugely important area which appears to have fallen out of fashion, even among its traditional advocates). But the NHS remains one of the most efficient health services in the world, despite its funding concerns, and the challenges it faces, principally demographic, while substantial, face every health service where populations are ageing. Furthermore, as the OECD has pointed out, ‘There is no health care system that performs systematically better in delivering cost-effective health care’. And general taxation remains an efficient way of raising funds, as the King’s Fund has pointed out.

Evidently, we will have to pay more in future but that is something most, I suspect, would be prepared to do. We should at least be aiming to match the EU average for health care spending. The argument that since other, different European healthcare systems are doing better in some respects, the NHS funding model doesn’t work, ignores the fact that these systems are better funded. There is, in other words, no prima facie case for abandoning the healthcare funding model we already have. The point I want to make is that, by all means, let us have a conversation but let us at least have an honest and open one in which all options are on the table.

The problem we face in the UK is that genuine choices, matters of our priorities as a society, are presented to the public as unavoidable outcomes of circumstances over which we have no real control. There just isn’t enough money to go around. Choices made by other countries, to better fund their health services or their education systems, are made to seem extreme, utterly unaffordable, the stuff of fantasy. Even the relatively modest proposals presented by the Labour Party in its last manifesto would ‘bankrupt the country’, we are told. Instead of the informed national conversation we so desperately need, we have a shouting match between those who supposedly think everything is affordable and those who think nothing is (or pretend to).

This is what I find so utterly discouraging about political debate in the UK. Not only do we lack a consensus as to the kind of society we want, or any meaningful sense of a social contract which might encompass all of us, we also have a media and political class which seem determined to prevent such a discussion taking place. When Jeremy Corbyn become leader of the Labour Party, promising a different, gentler style of politics, I hoped that he might be open to an inclusive debate within the party, to bring its different wings together – something that mirrored the kind of conversation we need to have as a country. Instead, the party now reflects its own divisions and those of the country more clearly than ever.

I don’t agree with those who believe that progressive policies can’t win at the ballot box. But I do think that meaningful, lasting change, needs inclusive politics that brings people out of their echo chambers and makes genuine debate possible. You cannot expect change to last if it is imposed on people who do not understand it and do not feel included in it. The British political landscape is a terribly divisive place right now, and there are far too few straws in the wind to make hope of change realistic. With Brexit looming ever closer, we are coming face to face with a reality which seems inevitable but which many people cannot bring themselves to accept, given the huge costs to the country it represents, and the damage it will do to people’s lives, particularly in places that are already struggling. The evidence on which people voted in the referendum is tainted, as are many of the people and organisations who campaigned on the leave side. Yet, even in these circumstances, there is hardly any mainstream political challenge to Brexit.

People feel unrepresented. In very many cases, they also feel desperate. Schools are struggling. The NHS is in crisis. Politics itself is in disarray. We are drifting into the future with no destination in mind and no map to guide us. Those who suggest we might pause a while to think about where we are going are pilloried in the press. How can we be dashing towards such radical change without any hint of a conversation about what kind of society we want to be? There is a gaping hole in the middle of British politics where just such a conversation should be taking place.

Politics is about choices. And democracy should mean we get to have a say about those choices. Any attempt to deny or limit those choices is, in effect, a subversion of democracy. There are many more options on the table than we are led to believe. We cannot have everything but we can have more and we can have different. We need to start being honest about who we are and what we want to be.