Simon Duffy

Thoughts, Bemusements & Arguments

Tag: healthcare

Welfare and the Common Good

My friend Virginia Moffatt recently edited a collection of essays called Reclaiming the Common Good which explores the way that society, in so many ways, seems to have lost its way. My essay explores some of the original thinking behind the welfare state and what we might do to return to the ideas that originally inspired it. The book launch was in Bloomsbury on 20th September 2017. Virginia asked several of the authors some questions, and here are my answers.

How would you define ‘welfare’? Why is it that we are currently living in a country where those in greatest need are being denied help?

A Finnish friend of mine, Katja Valkama, who was doing research on social policy in the UK asked me: “Why do people say all these negative things about ‘welfare’? In Finland welfare just means well-being.”

Exactly.

The term ‘welfare state’, was coined by Archbishop William Temple, and it was certainly meant to capture the idea that we needed to ensure that our social arrangements – underpinned by law, democracy and the power of the state – worked to guarantee everybody’s welfare – everybody’s well-being.

And the five main pillars of the welfare state still do so today:

  1. Health – The NHS provides us with universal healthcare
  2. Education – Public schools provide us with free education up to 18
  3. Income Security – Pensions and benefits provide some income security
  4. Housing – Housing benefits and social housing provide some protection from homelessness
  5. Disability Support – Local government provides some rather limited social care to people with disabilities and older people who are frail and need assistance

As my ordering suggest – some systems work much better than others and interestingly the ones we value most are:

  • The most universal ones, with no means-testing
  • The ones we forget are part of the welfare state

The word welfare – and its associated stigma – seems to attach itself most closely to social security and to any systems that seem to be just for the poor. This is despite the fact that the biggest benefit – accounting for about 50% of all benefits – is the state pension – a universal benefit. We have somehow allowed welfare and the welfare state to become stigmatised; this is despite the fact that the largest parts of the welfare state remain popular and so have been relatively protected from recent cuts.

On the other hand, the reason why the cuts of austerity have fallen so heavily on disabled people is that they are a group that is particularly dependent on the less universal elements of the welfare state: housing, care and benefits. These are politically easy things to cut because most people think they have no stake in them.

It is particularly important to recognise that our current problems are not so new. Things have been moving in this direction for several decades. For instance if we compare our situation today to the 1970s three things stand out:

  1. The poor have been made poorer, by a mixture of economic change and the lower value of benefits
  2. The rich have become a lot richer, but they do pay a little more in taxes
  3. Most people are in the middle and they are about the same – their wages have dropped, but the difference has been made up by benefits (disguised as tax credits, pensions, housing benefit etc.)

Austerity has recently made things much worse the poorest. But the system has been getting worse and worse for over 40 years. Over time its main function has shifted so as to subsidise the incomes of the middle-classes. But this has been managed in a way that enables them to psychologically distance themselves from those stigmatised groups that they see as beneath them. This is today’s double injustice: we steal from the poor, but heap blame and stigma on their shoulders at the same time.

What would you say to those who argue that the welfare state is no longer necessary in modern Britain?

It’s really important to realise that the development of the welfare state is correlated – above everything else – with the growing insecurity of the modern world. Our productivity or average wealth is irrelevant: people can starve or be forced into prostitution, homelessness or suicide even if society as a whole gets wealthier.

Average wealth is irrelevant, it is equality and income security – not economic growth that is most important.

In fact our amazing productivity has only been achieved by sacrificing (often not willingly) basic economic securities:

  1. First we lost the security of the land and millions were forced to come to the towns for work, and they then became dependent on ’employment’ and those who did not fit into this system were forced into the workhouse.
  2. Second craftsmen and labourers lost the security of their roles as machines produced more for less.
  3. Third we discovered, through the Great Depression, and many other bubbles, slumps and downturns, that even a job was no security. We can now manufacture droughts and famines through bad planning, economic anxiety and panic.

We discovered that the modern industrial world is no protection from growing inequality and radical insecurity – what Simone Weil calls rootlessness. These injustices then inspired revolutionary hopes and fascist reactions. This unleashed war, revolution, terror, eugenics and the Holocaust.

The welfare state – which had its seeds in Bismarck’s Germany – was always a way of replacing the basic securities that people desperately need in a world that had lost the older securities of land, church and community.

Nothing about the current state of the economy makes the welfare state less necessary. Income insecurity is even more extreme today than before the War. Our incomes are far more dependent on Government-run systems and subsidies. We simply take for granted the enormous benefits that come from the welfare state and the security – even its current inadequate form – that it provides for all of us.

We’ve gone to sleep and we’ve forgotten all that we’ve come to rely on.

The organisation you run is called the Centre for Welfare Reform. Can you give us some of your thoughts how the welfare state could be reformed for the good of all?

I do wonder whether it was a good idea to name the Centre as the Centre for Welfare Reform. The term ‘welfare reform’ is now so toxic and so closely associated with the changes introduced by the Coalition Government that it is quite confusing. However, I think that a civilised society will always want to ensure that it is organised in the best way it can be to ensure the welfare of all its members; so I think welfare reform – true welfare reform – actually improving how we take care of each other – will remain an important project – even if we’re not sure what to call it any more.

For me the central challenge of improving the welfare state was set out by the philosopher Jeremy Waldron:

Above all, I think the idea of citizenship should remain at the centre of modern political debates about social and economic arrangements. The concept of a citizen is that of a person who can hold their head high and participate fully and with dignity in the life of their society. (Liberal Rights, p. 308)

What this requires is up for debate, but I think we can mark out the two extremes that we must avoid – the Scylla (rocks) and Charybdis (whirlpool) of welfare reform between which we must steer:

  1. We must avoid the assumption that the state is some rational and benign entity who can be trusted to simply meet our needs and solve social problems on it own. This way of thinking is fundamentally undemocratic and it treats citizen as non-citizens – as passive, dependent and lacking in responsibility. The last 40 years, and particularly the last 7 years, have clearly demonstrated that the state cannot be left alone with this task of taking care of us.
  2. We must also avoid the assumption that we have no need for the welfare state, that we can all manage alone, or in our families. Citizens are not lone wolves, consumers or producers; they are people who need to live together and need to work together to build a meaningful and mutually rewarding world.

What this means is that we must look for welfare reforms that are going to encourage us to be the best that we can be both singly and together. We need to create a world where everyone is included, everyone is an equal, everyone is treated as a full and valued citizen.

So, what might some positive reforms look like?

Briefly I would suggest the following:

  1. The basic idea of the NHS remains sound – what we will want to do is bring it closer to our communities. Professionals sometimes forgot their core purpose – to teach, assist and enable.
  2. Schools needs to be freed from the tyranny of regulation and the phoney idea that they can prepare people for work. Education should be more inclusive and focus on building our capacity to be citizens.
  3. Income security needs to be radically reformed, and at its centre needs to be the idea of a basic income – a secure income that is enough for each of us to live a life of dignity.
  4. Housing needs to become a right and a fundamental responsibility of local communities must be to ensure everyone can live in their own community and not be forced out by increased housing costs. Citizens should belong where they live – and they should not be forced out of their communities by ‘market forces’. I believe a Land Value Tax, which ensure property owners support non-property owners will be the core reform required.
  5. Social care – or disability support – needs to be established as a universal, non-meanest-tested right for all of us. This is entirely possible and affordable.

Underpinning all of this – I believe – will have to be a resurgence of genuine democratic behaviour and of constitutional reform. People need to be free in order to be citizens, so that they can challenge, engage and collaborate in order to build the society we need. We will need new constitutional arrangements to establish, monitor and protect our human rights, and we will need a renewed civil society – with social organisations that are willing to speak out and stand up for justice.

I suspect that, along with secure social rights, established at a national level, we will need to pay much more attention to the local. Meaningful citizen action and community life can only becomes possible if some powers are decentralised and so people can focus on change at a personal, family and community level.

Of course much of this will seem a dream. But the post-war welfare state also seemed like a dream. I suspect it is only dreaming that will save us from years of further moral and social decline.

Can Socialism Reinvent Itself for the 21st Century?

I am a proud member of the Socialist Health Association. I feel strongly that decent healthcare is a basic human right and that nobody should be deprived of it because of poverty, nor should the wealthy be able to buy their way to longer or healthier lives. If this is socialism then I’m a big fan.

Recently, the Socialist Health Association decided to review its fundamental principles, and as a philosopher by training, I thought I’d try and help clarify what socialism, at the beginning of the 21st Century, really means. However this turns out to be a rather difficult task.

It is certainly clear that socialists are against greed, exploitation, inequality, capitalism (possibly) and injustice (certainly). But what are socialists for?

One clue might be found in the social- part of the word socialism. Socialists believe in society, and more specifically I think socialists believe that society should come before the individual, that individualism puts the cart before the horse. 1 Certainly, the Socialist Health Association’s first principle as it currently stands, reflect this:

“The claims of the individual should be subordinate to social codes that have collective well-being for their aim, irrespective of the extent to which this frustrates individual greed.”

Now, as a piece of English, this is somewhat dry, abstract and rather confusing.

First, there is the strange notion of “claims”. This is quite a peculiar word. What am I claiming and to whom? Why is anyone interested in my claims anyway?

Second, there is the notion of sub-ordination. In what sense are my claims meant to be subordinate? Must my desires, plans or projects be directed towards “collective well-being”? This seems totalitarian in its ambition.

Or, on the other hand, are my claims legitimate as long as they don’t directly contradict the “social code” which has (somehow) been identified as for the greater good? Perhaps I can claim the right to drink alcohol, but I must only do so to the extent allowed by the state. This is perhaps nanny-state socialism, a little more tolerant than the totalitarian version.

All of this seems to be far too strong and quite alien to my reasons for supporting the NHS and social justice. I don’t want to be slotted (tightly or loosely) into some social code for collective well-being. I want to live in a decent society where we treat each other as equals. I don’t want to tell people how to live; I just don’t want to be advantaged at the expense of others, or to see others so advantaged. I really like the fact that the NHS is organised to limit how someone can jump the queue to get a better or faster treatment than someone else with similar needs, but less money. It’s fair.

The third problem with this way of defining socialism is that we are often confused about which “collective” matters. We can be part of many collectives: the family, the tribe, the class, the nation or humanity as a whole. Sadly, it has not been too hard for the wicked to corrupt the ‘social’ inside socialism into one ideal group that should be valued above all others. There is more than a theoretical link between socialism and national socialism and the twentieth century has seen millions sacrificed on the competing altars of these deathly versions of socialism.

But it is possible to imagine a better kind of socialism and one clue can be found if we go back, beyond the word society, to its Latin root socius or friend.

Friendship has nothing to do with state power and control. C S Lewis was not alone in observing that, at its core, the relationship of friend-to-friend is not a relationship of dependence, assistance or charitable action. Friends get along, even love each other, but not ‘in order’ that they can help each other. Helping gets in the way of friendship, and this is why friends hate to be in debt to each other. An undue level of do-goodery and interference in the lives of others is also irritating and unhelpful. It is certainly not friendly.

The challenge for socialism, at a practical level, is to convert our commitment to justice and our proper sense of responsibility for each other into a way of living that is ethical and sustainable. People who live only for others are not much better than people who live wholly for themselves. Citizens understand that they have obligations to themselves and to other people.

In practice most socialists are not trying to create totalitarian states or nanny states and they are quite aware that all human being are equally important. Today, much of the moral imperative of socialism has been converted into support for the welfare state and for the social contract it seems to imply: I must be prepared to pay my taxes, and in return – and as an equal member of society – I become entitled to some rights, such as being able to get free healthcare.

Now this welfare-state-socialism seems relatively benign, however it still has some peculiarities. For instance, notice that in this example of day-to-day socialism, the agent of good is now no longer acting from any moral principle. The doctor is not treating you because she’s a good person; instead she is (very) well paid to treat you. It is not the doctor who helps you, it is the anonymous welfare state, it is the system. So, interestingly, in order to operationalise itself socialism, appears to have moved away from the notion of friendship or mutuality. If we are not careful, the whole thing starts to feel entirely mechanical or transactional. I do this in order to get that. But then what is the difference between this kind of welfare-state-socialism and the kind of left-leaning liberalism that sees the welfare state as form of national insurance: we all put something in (according to our means) and we all get something out (according to our needs).

What seems to be missing is any deeper sense of our responsibility to our community, or even a sense of our unique individual value. Society has been converted from human-sized communities into a vast state-run charity. This may be a charity from which we all benefit, but as Arendt says, “charity is not solidarity.” In the face of this monolithic system we each become one part donor and one part recipient, one part tax payer, one part service user. The uniqueness and value of ourself and of our community disappears from view.

Welfare-state socialism is much better than totalitarian or many-state totalitarianism and much better than heartless forms of liberalism and individuals. But does it not feel we’ve sacrificed too much? Is there not a better way of defining socialism for the 21st century?

The fact that the meaning of socialism can be corrupted is no reason to abandon it, nor to abandon the concerns that it was developed to address. The underlying reasons for socialism are as real today as they were yesterday. Economic forces and greed do not control themselves; even the minimal democratic control of the state which we ‘enjoy’ today is no guarantee of justice, particularly when power and influence seems so easy to purchase. It remains essential that we examine what is really to the benefit of society, and not to treat society as if it were merely equivalent to a mass of self-interest.

However, if socialism is going to thrive we must find a better version of socialism.

For me the best starting point is the idea of citizenship. To be a citizen is to be much more than taxpayer, much more than a voter and much more than a right-holder or recipient. Citizens make community; their actions, innovations and creativity are the source of social value. They may be prepared, in extremis, to die for their community – but actually, more often, they get to live for their community.

The model of citizenship I use has seven elements, and I think each could be explored to develop a reinvigorated and healthier sense of what socialism might mean:

  1. Purpose – Citizens have a sense of purpose which is encouraged and supported; today’s dreams are tomorrow’s solutions.
  2. Freedom – Citizens are free, free to do their own thing, free to work with others, free to do the unexpected.
  3. Money – Citizens have enough, they abhor poverty and they don’t like excessive inequality (Plato’s suggested 1:5 income ratio for poor to rich would be much better than today’s tasteless and destructive excess.)
  4. Home – Citizens have homes, roots, neighbours and a sense of belonging. They are part of the community and they construct that community.
  5. Help – Citizens help each other, need each other, and know there is no shame in getting some assistance. However, what citizens don’t tolerate is sacrificing their freedom in order to get that assistance.
  6. Life – Citizens live life to the full, they work (and they know paid work is only one kind of work) they rest and they play. Citizens seek balance and know that you can only get out of life what you put into it.
  7. Love – Citizens need love, cherish love and respect love. Family, friendship and loving partnerships are all aspects of life that citizens nurture and protect.

Defining 21st Century Socialism seems a worthwhile project. The key I think is to leave behind the paternalism of the welfare-state-socialism and to rediscover the spirit of citizenship and community which actually built the welfare state in the first place. This does not mean abandoning the welfare state; it means reinvigorating and redesigning the welfare state. We must build the welfare state again, but this time not bury its builders and architects beneath its edifice.

  1. This point has a long pedigree; Aristotle, for instance offers us an early version of socialism “…even if the good of the community coincides with that of the individual, it is clearly a greater and more perfect thing to achieve and preserve that of a community; for while it is desirable to secure what is good in the case of an individual, to do so in the case of a people or a state is something finer and more sublime.” ↩︎

We’re Getting Older – Don’t Panic, Don’t Panic!!

Some days seem to have a curious symmetry to them, and this week I have had one of those days. It began in the heart of the Whitehall and it ended in a community radio station in East London; but the theme at the heart of the day was constant: what does it mean that we are now living longer?

The first discussion was a roundtable with some of the leading academics and experts in health and social care. (If you are wondering why I was there then you are not alone; I don’t know either, but I was certainly happy to have been invited.) It was chaired by the excellent Professor Martin Knapp of the London School of Economics and we were being asked to think about the implications of ageing on health and social care.

I was asked to say a few words about the impact of longer lives on our ability: “to provide and procure care” although, as I tried to argue, I think this is entirely the wrong way to frame the question. The real question is “how do we support each other as we live longer.”

What I tried to communicate was that there is no evidence that our growing health, and our longer lifespans, will create any crisis. These facts should be a source of celebration. Yet, there is almost no social change, even social progress, which cannot be turned into a crisis if it’s handled in the wrong way.

In my presentation I used data from a report by The Centre for Welfare Reform that we will be publishing in a few months. I had carried out an analysis of of disability, healthcare, social care and community capacity in Barnsley, where:

  • 2% of the population were in very bad health
  • 7% were in bad health
  • 13% had a disability (this group will overlap with the first two to some extent)

Barnsley spent £60 million on social care, however this figure is dwarfed by the care that the citizens of Barnsley provide to each other without pay.

If Barnsley had to pay for the support that is already being provided free, by carers (the official jargon for family and friends) then it would have to spend about £600 million. In other words the support provided by families is about 10 times greater than the support paid for by the community via taxation.

Furthermore, we can go on to estimate how much time and energy is potentially available to the town – what we could call its ‘community capacity’. You can do this by looking at how many people live in Barnsley (about 250,000) and then taking away all the time spent on being a child, time lost to paid work, time in education, time spent caring and time used for ordinary amounts of rest and leisure. This leaves you with an estimate for how much ‘community capacity’ is available. For Barnsley that is equivalent 65,000 whole time equivalent people, with an economic value of over £1 billion.

There is an army of community capacity potentially available to any community (unless its working too hard) and this capacity is probably over 20 times greater than what is spent on social care.

We are society with immense financial wealth, in addition we already have all the human capacity necessary to provide the care and support that we need to look after each other. We will all go through the shared human experiences of sickness, age, disability and death; but we certainly have the resources necessary to ensure that we can all do this in ways that ensure our dignity and mutual respect.

If we focused on our immense community capacity available then there would be no sense of crisis. However community capacity is undermined by a series of negative factors that are driven by Government policy and by the interests of the powerful:

  1. Cuts to social care – Local government funding from central Government has fallen by more than 30% in 6 years and is projected to fall further. Central Government funding used to provide 75% of local government finance. Cuts to social care have been deep and we have seen the number of people supported fall by well over 30% in the same period. I assume that local Government has had to cut its most efficient and low cost supports first, leaving it with a growing percentage of its budget invested in expensive and institutional provision, which is harder to cut. I do not see how the obligations of the Care Act 2014 can be balanced with the desperate situation of local government.
  2. Means-testing of social care – The extreme means-testing of social care does what all means-testing does – it reduces social solidarity and encourages people to divest themselves of their own wealth if they are at any risk of needing social care. This further undermines community capacity and faith in the community’s capacity to support people to get the necessary additional finances they need when illness or disability develops.
  3. Inequality and poor productivity – The UK is the most unequal country in Europe with low productivity and high employment rates. Or to put this another way, more people are having to work longer hours to maintain even a very modest income. For instance, increasingly both partners in a typical family need to work to maintain a modest income, leaving less time for caring or for citizen action. Economic inefficiency and extreme inequality both have the impact of minimising available time for citizen action and community capacity.
  4. Workfare and the collapse of the voluntary sector – There are two powerful but inane dogmas that dominate public policy in the UK: (1) the only useful activity you can do is earn a salary and so pay taxes and (2) the best people to find people work or volunteering opportunities are the DWP or their private-sector agents. Clearly these ridiculous assumptions undermine our ability to tap into people’s real gifts and skills.

So it seems we are in the process of turning what is an opportunity for a longer richer lives into a severe social crisis. We lock a higher proportion of our increasingly limited financial resources into professionalised and institutional care; so we will then be only able to offer support to fewer numbers of people who will be in severe crisis. Alongside institutional care, micro-institutionalisation and the misuse of technology to ‘keep people safe’ will probably grow. At the same time fewer families will feel that they can afford to take care of their own relatives and will so demand ‘care’ from a system that will not be able to offer them support until they reach breaking point. The ongoing pressure to allow euthanasia is consistent with this crazy system problem.

The sad thing is that, while there are so many clever and well intentioned people in the central and local government, it just seems impossible to shift discussion away from the minor problem of ‘funding social care’ to the major opportunity of ‘supporting community capacity.’ It is cynical to think that this is only because a crisis is much more useful to the political elites, but Mencken’s often quoted proposition does sometimes feel so true:

“The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary.”

Perhaps, but I hope this is not true, the powerful do not want to recognise that releasing community capacity is about freedom and empowerment. The real solutions we need – those generated by people, families and communities – all require freedom and creativity in order to exist. The great innovations we are seeing from organisations like PFG Doncaster, WomenCentre, IBK Initiatives, Best Buddies UK, and so many more, are all rooted in an awareness that we are free citizens who can choose to act to benefit ourselves and our community.

Capacity is rooted in the actions of free citizens, working together in community. Such capacity cannot be bought, it cannot be bossed, it can only be enabled, supported and liberated.

Despite my fears it was encouraging that so many in the discussion did share my sense of disquiet at the danger of accepting inequality and an on-going public service crisis as the inevitable background to policy-making. But one could still feel the gravitational pull in our discussion of these hobgoblin problems: the fear of increased costs, the fear of increased rationing and fear about what will happen to us at the end of our lives.

After this discussion I was lucky enough to be invited to East London Radio, to be interviewed by Mervyn Eastman. Mervyn Eastman is an inspiring leader and social worker who has established the Change Agents Coop with the wonderful Cheryl Barrott. The Centre for Welfare Reform has recently joined the Coop as an organisational member.

Together we discussed how the idea of citizenship must become central to our thinking about ageing. Citizenship, everyday citizenship, is the foundation for building a good life for ourselves and building good communities together. We explored how old age was not a problem; but a society that insists on treating it as a problem will certainly end up creating one.

What made this radio interview especially sweet was that I was able to indulge my love of music. A rather sad admission on my part is that I have always dreamed about what I would choose if I was ever invited on Desert Island Discs or on Radio 3’s Private Passions. For East London Radio I picked:

  • Communication Breakdown by Led Zeppelin
  • The Nightwatch by King Crimson
  • Anyway by The Roches
  • A Survivor from Warsaw by Arnold Schoenberg

As I left the studio, to head home to Sheffield, I found myself in the community cafe and bookshop that was also the home of the community radio station. On the shelves were some fantastic European novels I’d not heard of and so I indulged myself by buying 4 books to take home.

So my day ended with this sense of contrast. On the one hand, in the bowels of Whitehall, intelligent people were struggling, against the grain, to stop the system turning old age into a new social problem. Meanwhile, on the streets of East London, ordinary people were busy building, sharing and supporting one another to lead richer, better lives.

As ever Christ’s words help. The Vulgate puts it as “sufficit diei malitia sua” which could be loosely translated it as: Start by tackling today’s injustices.

If Government really wants to help us ensure that we can take good care of each other in the future then there are four pressing problems it could tackle now:

  1. Protect social care funding
  2. End social care means-testing
  3. Radically reduce income inequality
  4. End the stigma and control of the DWP’s benefit systems

Do those 4 things and human capacity will flourish and many of tomorrow’s problems will never arise.

Medical Power & Personal Health Budgets

The modern doctor evokes respect and awe, mixed with some fear and suspicion. At the most basic level a power relationship starts to exist as soon as we feel that another person holds in their hands an important key to our own life, death or happiness. We feel that we need them and this gives them power. However modern medicine reinforces this age-old pattern of dependency further because of the enormous progress made by modern medical science; progress which is underpinned by an interlocking system of research, education, accreditation, power and money. So, to put this another way, for thousands of years doctors have had power over patients; but since the development of modern medicine in this power has grown considerably – because modern medicine really works.

Ultimately Personal Health Budgets cannot be understood without thinking about this relationship, because it is an innovation within the doctor-patient relationship. It is not an innovation that effects everything in medicine directly; for there are many areas of modern medicine where the use of Personal Health Budgets would be entirely inappropriate. However it does create the possibility of a new kind of partnership between doctors and patients – at certain points – and as such this does start to change the whole relationship.

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