Category: Social Policy

This occasional blog discusses issues in Social Policy.

Is the NHS the best health care service?

An international ranking of health services in 11 countries rates the UK NHS at the top.  The Commonwealth Fund, an American think-tank, ranks health systems on five main criteria:  Access, Equity, the Care Process, Administrative Efficiency and Health Outcomes.  Each of those criteria is based in turn  on a range of subordinate indicators:  the “Care Process”, for example, takes into account prevention, safe care, coordination, and patient engagement.  It’s backed up further by more detailed assessment;  for example, the US does badly on infant mortality and premature death, but relatively well in relation to doctor-patient relationships and the management of stroke.  But speaking as a carer, I find it hard to believe that the state of our mental health services really represents the best that anyone can do.

The main purpose of the report is to give a critical perspective on health care in the US, which is outstandingly expensive as well as being the least effective of the systems; but there are questions to raise about other countries, too.  For the UK, we might wonder how it is that the health care system is ranked top of the league while the UK’s health outcomes are the second worst in the table.   The neo-liberal Institute of Economic Affairs commented, acerbically: “the NHS’s provision of care is equally poor for everybody, irrespective of income.”

 

My doubts about ‘food sovereignty’

I was asked to act as a discussant for a paper on ‘food sovereignty’.  Food sovereignty is an idea being promoted by Via Campesina.  Via Campesina “defends small-scale sustainable peasant agriculture as a way to promote social justice and dignity based on food sovereignty.” They describe food sovereignty in these terms:

Food sovereignty is the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods, and their right to define their own food and agriculture systems. It puts the aspirations and needs of those who produce, distribute and consume food at the heart of food systems and policies rather than the demands of markets and corporations. … Food sovereignty implies new social relations free of oppression and inequality between men and women, peoples, racial groups, social and economic classes and generations.

It sounds very warm and human, but it’s a muddled, ill-considered set of claims.  The core problem with it is that food sovereignty doesn’t protect food security – people’s right to have food to eat.  It protects the interests of producers, not populations.  The second problem is that it can’t offer a response to significant vulnerabilities, such as civil war, drought or climate change; if (or when) such things happen, the localities where they happen will be not be protected by a system that is relatively localised.  Third, providing healthy diets locally and on the small scale must mean less food.  That’s true partly because it’s only possible to provide varied diets locally by growing things that grow less well locally as well as those that grow better, and partly because comparative advantage is lost – less specialisation and less trade means less food.  Fourth, for what it’s worth, there’s absolutely no reason to assume, as this declaration assumes, that local production will be ecologically sound.  Why should it be?  Finally, food sovereignty can’t deal with the distributive issues within societies.  There’s reason in some aspects, such as gender relations,  to believe it won’t.

More troubling still is the ranting, anti-capitalist wrapping this comes in. This is from the Via Campesina website:

For too many years, we have witnessed with deep pain the systematic plunder and destruction of our precious natural resources and the oppression of our people. We know that our African elites in the public and private sectors have been for many years colluding in corruption with the evil transnational corporations which today represent the new face of imperialist neo-colonialism. We are appalled by this and demand an immediate end to immoral and irresponsible behaviour of many of our leaders.

This is the authentic voice of populist demagoguery.  Populism has been defined as

an ideology that considers society to be ultimately separated into two homogeneous and antagonistic groups, ‘the pure people’ versus ‘the corrupt elite’, and which argues that politics should be an expression of the volonté générale (general will) of the people.  (C Mudde, 2004, The populist zeitgeist Government and Opposition 39 (4), 541–63.)

an ideology which pits a virtuous and homogeneous people against a set of elites and dangerous ‘others’ who are together depicted as depriving (or attempting to deprive) the sovereign people of their rights, values, prosperity, identity and voice.  (D Albertazzi, D McDonnell (eds) 2008, Twenty first century populism, Palgrave Macmillan, p 34)

The examples I heard about today manipulate people’s concerns to push forward an authoritarian, collectivised, exclusive model.   This doctrine is not just foolish, but sinister.

Principles of Social Welfare is now out in Arabic

I’m pleased to report the appearance of an Arabic version of one of my books, Principles of Social Welfare.   Translations don’t of course count for anything in academic sports days, and I’m on the sidelines anyway, but it’s gratifying.  For anyone who prefers the original English, you’ll find a copy on my open access page.

A failure of emergency planning

Following the dreadful events in North Kensington, much of the public criticism has been directed at national politicians.  They’re not exempt from their part of the responsibility, but the PM’s office is not where the primary authority, or responsibility, rests.   Every local authority in the UK has a statutory duty to make plans for emergencies, and the first question should have been about what the local authority was doing to implement its emergency plan. Kensington and Chelsea formed their most recent plan, dated 2015,  in conjunction with Hammersmith and Fulham; the coordination of arrangements with Hammersmith and Fulham is scheduled to come to an end next year, but that does not excuse any failure now.  The emergency plan can be found here, on the Hammersmith and Fulham site (on page 6, it’s co-signed by the responsible K & C officer).   It tells us that what the local authority was expected to do, and they should have been ready to do within three hours of the reported incident (the three-hour guideline is on page 10; during a working day, it should have been activated within 45 minutes).  This, from page 17, identifies specifically the roles that the local authority might be expected to fulfil:

Maintaining statutory services at an appropriate level, wherever possible.

Supporting the emergency services and other organisations involved in the immediate response. This could include:

  • Clearance of debris and restoration of roadways, provision of engineering services and emergency signing.
  • Structural advice, and making safe or demolition of dangerous
    structures.
  • Assistance in the evacuation of the civilian population.
  • Provision of premises for Body Holding Centres, Survivor Reception Centres, Friends and Relatives Reception Centres, briefing and rest facilities for emergency services personnel.
  • Provision of a Temporary Mortuary.

Providing support services for the community and others affected by the incident. This could include:

  • Provision of Emergency Rest Centres, with food and beverages, beds, and welfare services.
  • Provision of a Humanitarian Assistance Centre.
  • Provision of emergency sanitation and hygiene services.
  • Re-housing of those made homeless, in both the short and long term.
  • Inspection of and emergency repairs to housing.
  • Environmental health management.
  • Implementation of measures to control the spread of disease.
  • Establishing Community Assistance Centres for the dissemination of information and support to those affected by the emergency.

Enabling the community to recover and return to normality as soon as possible.

Given the failure of the local authority to provide most of this, it is not surprising that they have not sought to use their existing powers more extensively – such as the power to promote welfare, to purchase property voluntarily, or to invoke compulsory purchases.  But that is what would happen in much of continental Europe  – for example, when Jacques Chirac, as mayor of Paris, effectively commandeered empty property in the rue du Dragon for use by homeless people.  (Chirac, in case people have forgotten, was a conservative.)   That was done by agreement, under threat of requisition.  There are places in North Kensington where the displaced people could live.

 

Preventing terrorism

In heath care, it’s long been conventional to refer to two or three classes of prevention.

  • Primary prevention is about implies stopping a person from developing a problem in the first place.  It can be done by
    • changing the environment, which has been been the approach of public health services;
    • changing people’s behaviour.  This is attempted through health education; advertising; legal restrictions, like licensing of pubs; and financial disincentives, like taxation on cigarettes and alcohol; or
    • changing people’s physical condition.  Vaccination is the obvious example.
  • Secondary prevention.  This implies identifying a problem in its early stages to prevent its progression, for example through screening of women for breast and cervical cancer.
  • The third class, tertiary prevention, is not used as widely  as the others, because the category is difficult to distinguish from treatment; it aims to reduce the impact of an illness that has happened, or treating diseases so as to stop them from spreading.  To stop cancer recurring, for example, treatment has to be thorough and comprehensive.

It ought to be possible to extend this classification to other things we need to prevent.  I don’t claim to know much about terrorism, but it seems to me obvious that we cannot describe policing of any kind as the “front line” dealing with the problem.  The front line is primary: the people who occupy it include teachers, religious leaders and the broader public.  Primary prevention would aim to change culture, attitudes and behaviour at the source, through social inclusion, education, and civic engagement.  Community policing and early detection by the security services – the focus of much of the present debate – are forms of secondary prevention.  Control orders or the  “Prevent” programme, which respond to stop committed terrorists from acting on their convictions, are tertiary. The response of successive governments in the UK has been heavily geared to tertiary prevention, and that means that while it can limit the damage, it comes in too late for effective prevention.

The Conservative Manifesto speaks to the shade of Edmund Burke

The Conservative Manifesto, Forward, together, is quite an unusual document.  Yes, there’s a  lot about strong and stable leadership – the word ‘strong’ or ‘stronger’ comes in there 86 times, I counted them in and I counted them back again  – but there’s a lot more, including some ringing declarations of principle.  We are told that

“We believe in the good that government can do.”

“Conservatism is not and never has been the philosophy described by caricaturists. We do not believe in untrammelled free markets. We reject the cult of selfish individualism. We abhor social division, injustice, unfairness and inequality. We see rigid dogma and ideology not just as needless but dangerous.”

“Our National Health Service … is founded on the principle that those who have should  help those who do not. It is a system of solidarity to which we all contribute, not just to help us and our families when we are in need but to protect others in our community when they need help too. This not just expediency: we do it because the support we give each other ties us together.”

“We know that our responsibility to one another is greater than the rights we hold as individuals. We know that we all have obligations to one another, because that is what community and nation demands. We understand that nobody, however powerful, has succeeded alone and that we all therefore have a debt to others. We respect the fact that society is a contract between the generations: a partnership between those who are living, those who have lived before us, and those who are yet to be born.”

(The last bit of that sentence, unattributed, is nearly a quotation from Burke – Burke wrote ‘the dead’ rather than ‘those have lived before us’, but presumably they didn’t want to imply that the National Health Service was a partnership with the dead.  The first part of the sentence is nearly a quotation from Jacques Delors, but that’s another story.)

In relation to policy, there’s a long list but a  little less meat.  There are ‘no plans’ for further changes in benefits; things will go on as they have.  More money will be spent on the NHS.  There will be a million more homes 2015-20 (that’s 200,000 an year) and half a million more by 2022 (250,000 a year).  All pledges are carefully tied to the life of forthcoming parliament.   But there are also tantalising hints that there might be more coming.  There will be a reform of medical education.There will be a review of taxation, aimed at simplification.  There will be a review of university funding.  They will review access for disabled people.  They will review the operation of the NHS internal market.  I don’t know what any of those actually means, but they could come with a cartful of surprises.  Perhaps the policy makers might take another lesson from Burke:  “the deliberations of calamity are rarely wise.”

 

 

The Scottish Conservatives have changed their mind about prescriptions.

The Scottish Conservatives have abandoned their long-held opposition to free prescriptions, and now accept  that free prescriptions are popular and practical.  A Conservative spokesman explained:  “There is no doubt people in Scotland value the idea of free prescriptions. We have listened to them and changed our policy.”

The case for free prescriptions is straightforward.   As things stood before the policy, and as I believe they still stand in England, five out of six prescriptions were exempt anyway – for pensioners, for children, for people on low income, for prescriptions issued by hospitals and for a wide range of specified medical conditions.  There is already a means-test to make sure that richer people pay; it is called ‘taxation’.  Introducing a further means test for people on lower incomes simply adds to the administrative burden.  So people were being subjected to an awkward, complex and sometimes intrusive process which raised relatively little money.

The Conservative announcement has been met with howls of derision by the opposing parties.  The change in policy has described the change of heart as ‘opportunistic’, ‘untrustworthy’, ‘shambolic’, ’embarrassing’ and ‘humiliating’.  I suppose that that reaction might make sense to politicos of a tribal disposition, but credit where credit is due:  the new policy should be welcomed.  This is a triumph of reasoned argument over political prejudgment, and if it is a reflection of the fact we’re now in an election campaign, it’s also a triumph of democracy over ideology.  There is joy in heaven for the sinner who repents.

The IEA condemns the “Nanny State”

The Institute  of Economic Affairs has published an index ranking European countries on a “Nanny State Index”.  The index is based on their ratings on four issues:  the  freedom to smoke, to drink alcohol, to eat junk food and to use e-cigarettes.   Finland is the “least free”; the UK comes second.  The Czech Republic is “most free”.

Many people on the neo-liberal right take a peculiarly restricted view of freedom.  Freedom is usually defined in terms of non-interference.  Hayek argues, in The Constitution of Liberty, that someone does not cease to be free if they are trapped on a mountain (it’s an odd example, but he was Austrian).  On the other hand, their freedom might be infringed if someone sent mountain rescue to help them out without getting their permission first.

The main justification neo-liberals accept for intervention is to protect the freedom of others.  It doesn’t seem to matter that smoking threatens non-smokers, that alcohol fuels violence and accidents or that junk food is aimed at children.  Those arguments might be persuasive in themselves – we hear them a lot – but none of them gets to the heart of the reason why we need public health measures.   Smoking, alcohol and sugar have together been responsible for much of the premature death and disability in the UK – far more dangerous than terrorism, roads, HIV, pollution or anything else we might name.   The freedom that the IEA is defending is the freedom to die early, to be subject to crippling disease, and to have firms pass off poisonous junk on the public because the only freedom that matters is the freedom of the producer.   Public health is not the threat to freedom.  The people who peddle this stuff are.

On the Labour manifesto

I had hoped that by now all the party manifestos would be available for review.  It seems that in our new, populist politics that policies don’t really matter that much, and everyone is waiting for a more opportune moment to reveal their plans.   The first manifesto off the stocks turns out to be the Labour Party’s, and that’s only because the manifesto has been leaked:  I read it via Guido Fawkes’ site.  It’s wordy, and there’s a lot of detail on some areas – just not the ones I usually get worked up about.

The main policies on social security are to

  • keep the triple lock on pensions
  • ‘review’ pension age
  • ‘review’ the two child policy
  • scrap sanctions
  • reverse a series of cuts, such as the bedroom tax and recent cuts to ESA
  • replace assessments with a “personalised, holistic assessment process”, and
  • restore Universal Credit work allowances.

That looks, then, like a commitment to retain Universal Credit, and indeed most of the current structure of benefits; the biggest commitment is to roll back benefits to how they were five years ago.

On housing, Labour will build more.

On health, the main commitment is to spend more and to cap waiting lists at 18 weeks. For mental health, the main  commitment is to spend more proportionally, and to do more about children’s mental health. For social care, care workers will be paid more.

The summary may seem sketchy; so, in my view, are the proposals.  There is rather more on transport, business and energy. Nor is there much about general principles, such as liberty, equality, solidarity or democracy.  The old-fashioned, fuddy-duddy stuff that excites me is just not what Labour is most concerned with.

 

Criticism of a complacent Fabian

Apparently I’m a complacent Fabian.  I’ve just got round to reading Peter Beresford’s book, All our welfare (Policy Press, 2016).  Throughout his career he’s argued consistently for greater participation and empowerment for user services.  This is not his best work – I wanted to see more about what he’s proposing – but it continues to make the case.  He doesn’t like conventional studies in Social Policy (he lays into Peter Townsend at some length), and he certainly doesn’t like what I’ve written.  He cites this section from my text on Social Policy.  To keep the comments in context, I’ve bracketed off some bits he’s left out.

[The recipients of social services are not only disadvantaged in terms of their relationship with producers … The stigmatisation of recipients, their lack of resources and status, and their vulnerability pose important problems for the social services.  The development of formal mechanisms for protection, and substantive rights, offers a means by which the people who receive services are not solely dependent on decisions made by the producers of welfare; these rights represent one of the most important means through which recipients can be empowered.  But the social disadvantages remain;] people who are poor, disabled, mentally ill or unemployed cannot be expected to overcome the problems they face simply because they have more effective control over services.  [There are then limits to what it is possible to achieve in the narrow context of service delivery.]  It is important, too, not to overestimate the potential effects of this kind of procedure.  Dwyer lists some of the key objections to user-based approaches.  There are conflicts of interest between users of different types; users are often in competition for scarce resources with others; user groups can lose touch with their grass roots; and the process as a whole can contribute to the exclusion of marginal groups.

Last year I posted some material from a text that was complaining that I was part of a left-wing conspiracy.  Now it seems I’m part of another one, to suppress people who are marginalised.  Beresford writes (pp 355, 363):

It is difficult … not to detect some degree of complacency in social policy academic writings.  These have shown a reluctance to take on the bold new ideas and arguments developed by welfare user movements.  A strong sense of Fabian ‘business as usual’ lingers.  … [This] leads to one, more privileged, group offering its prescriptions for another, marginalised and devalued, group.  How else can we explain the routine exclusions that books like Spicker’s seems to rest on?