Category: Social Policy

This occasional blog discusses issues in Social Policy.

Good news from Africa

This table is drawn from a recent study looking at the fall of mortality in Kenya. It points to a general trend: across Africa, more children are surviving.

Under 5 mortality (per 1000 live births)
Previous studies (1998-2007)

Most recent study (2005-2009)
Benin

160 (2001)

125 (2006)
Ethiopia

166 (2000)

124 (2005)
Ghana

111 (2003)

80 (2008)
Kenya

115 (2003)

74 (2009)
Liberia

110 (2007)

114 (2009)
Madagascar

94 (2004)

72 (2009)
Mali

229 (2001)

191 (2006)
Namibia

62 (2000)

69 (2007)
Niger

274 (1998)

198 (2006)
Nigeria

201 (2003)

157 (2008)
Rwanda

152 (2005)

103 (2008)
Senegal

121 (2005)

85 (2009)
Tanzania

147 (1999)

112 (2005)
Uganda

152 (2001)

128 (2006)
Zambia

168 (2002)

119 (2007)
Zimbabwe

102 (1999)

83 (2006)

Stephen Radelet, in Emerging Africa?, claims that the factors behind this improvement are

  • “more democratic and accountable governments
  • more sensible economic policies,
  • the end of the debt crisis and major changes in relationships with the international community
  • new technologies that are creating new opportunities for business and political accountability, and
  • a new generation of policymakers, activists, and business leaders.”

There are problems – such as the recent (hopefully short term) increase in mortality in Liberia. But the trend is clear, and it is very good news indeed – especially for those who are concerned about population increase, because there is a clear and strong association between infant survival and the number of children a woman must have.

Life expectancy and pensions

A report by PWC on pensions draws attention to some fairly startling projections about life expectancy; they claim that pensioners born in 2050 will have an average life expectancy of 104. The source of the prediction are tables produced by the Office of National Statistics – this link goes to their main projection. For people born in 2050, the projection is that 48.4% of males, and 55% of females, will live to 100. The ONS also note that “As only one person worldwide has ever been verified as living beyond 120, estimates of numbers surviving to very old ages are highly uncertain.”

There are no strong reasons here for immediate panic. Even if the pension age stays at 66, people born today will not get their pension until 2078; and the troublingly long-lived babies of 2050 will get their pension in 2116. That is far enough away for our great grandchildren to be able to do the sums, probably a little more effectively than we can.

Value for money in child care

The recent events in Rochdale, where under-age girls were forced into prostitution, have mainly focused on other issues. Prostitution has been a long-standing problem for young people in care – vulnerable teenagers who have been abused and sexualised at a young age, are often open to the opportunity, and no institution has ever found a satisfactory resolution. One of the issues which came out of the recent case was that one young girl who was placed in a single unit, with six full time workers, nevertheless managed to spend one or two nights a week out – 19 times in three months, which sounds worse.

The cost of this private unit has been reported variously at £225,000 to £250,000 a year. Most authorities have some children farmed out in this sort of arrangement. That poses a question which has mainly been considered at much lower levels of need – whether such intensive childcare is justifiable. We know that the outcomes of formal care are generally poor, and that many arrangements end up making things worse. But there is a standard, default comparison: how a child would fare in substitute family care instead. What are the objections to paying a full-time foster parent a living income – say, £40,000 a year – instead of paying £225,000 for six-full time workers?

There are four main objections, and none of them seems to me to stack up. The first is professional training. I think we have to ask what a very damaged child needs to have provided on a 24 hour, 365 basis – thoughtful, systematic intervention or a secure, protective life style. There is no reason why these cannot both be done – but also no reason why they have to be done at the same time. The second is the variable quality of foster care, including – in the worst cases – abuse. That is true, but the same is true of residential units. Many local authorities take the view that they cannot pass an ungovernable child to any but the best foster parent. While I understand their reticence, the illusion is that they have a better option in residential care.

The third is that it is not possible to pay someone a large amount of money in a fostering allowance without treating them as an employee. That’s not right – this is family support, and family support doesn’t have respite or hourly rates of pay – but clarification of the law would help. The fourth is that while one can pass legal responsibility to a private provider, a local authority cannot pass it to a foster parent. That is true, but it shouldn’t matter. Local authorities are not minimising harm to a child by keeping the child in residential care instead. In relation to the third and fourth points, both hang on current constructions of legal responsibility. If the law is working against the child’s best interests, we should change it.

There are no general rules, but in every case where a child is in residential care, the question needs at least to be asked: why is this child not in substitute family care instead? If the only objections are the four I have mentioned, they should be overruled. Increasing the use of substitute care in the most difficult circumstances will inevitably lead to some bad decisions, and some disasters, but let’s be blunt: it’s disastrous now.

Personalisation falls short

This is the abstract of an article I’ve written, newly published in the British Journal of Social Work.

Personalisation offers individualised treatment in circumstances where markets do not operate. Personalisation is described variously as a process involving an individualised assessment and response, the expression of individual preferences and choices, or a process in which users and professionals negotiate a common understanding of the needs of the individual. The core arguments for individualised approaches are effectiveness, efficiency and responsiveness to need. However, personalisation sometimes falls short of the claims made for it. It is not always effective, because matching people to resources is time-consuming, difficult and dependent on so many conditions that mismatches are inevitable. It may be inefficient, because it is difficult to deliver selective services without either misplaced provision or inappropriate denial of service. There is only limited support to be found for the belief that services have become more responsive to individual circumstances as a consequence of personalisation, or that they are better matched to need. The case for personalisation has to be argued and proved in the context in which it is applied.

Liberty before liberalism

I am currently putting the finishing touches on a book considering the relationship between individualist thought and welfare policy. I’ve just attended two fascinating sessions given by Quentin Skinner, the intellectual historian, who explained what was, to me, a completely unfamiliar different way of understanding the idea of liberty. In Roman law, he explains, freedom was a status, not a course of action; the distinction between freedom and slavery rested not on individual choice, but on domination, dependency and subjection to arbitrary power. Within the neo-Roman or “Republican” model, people lose their freedom, not so much because they are interfered with by laws, but because they have a status which is subject to the decisions of others. There is, arguably, a lesson for contemporary welfare states in the construction of our social rights.

Tax relief for charitable donation

The purpose of tax reliefs on charitable donations is intended, in part, to limit abusive tax avoidance, but there are points of principle to consider. Whenever tax relief is given, the state is foregoing the tax revenue it could otherwise claim; effectively, the charity is receiving money that would otherwise have gone to the government. Charities are already exempt from a range of taxes, particularly council tax and water rates. Charities which raise money by asking people to declare that they are are taxpayers are effectively seeking – and receving – government subsidy. The idea that this is “free” money is illusory.

The support of “philanthropy” by tax relief effectively means that people are able to give money to charities in lieu of giving it to government – a situation which puts individual preference in place of collective decision making. What a phalanx of very rich “philanthropists” are demanding is that they, not the government, should be able to determine how their tax liabilities are spent. The US Government accepts that demand, unreasonable as it is, and the US functions consistently with the federal government in deficit as a result. Most European governments would not tolerate it, and they should not.

Physical activity and sport

I’ve been looking belatedly at the Scottish Health Survey 2010, published six months ago. In the report of the 2008 survey, physical activity is broken down into four categories:

  • heavy housework
  • manual labour, gardening and DIY
  • walking, and
  • sport and exercise.

Housework is consistently the most important category; specific engagement in sport and exercise decline rapidly as people get older. In the 2010 report, figures for housework, domestic activity and walking are not given, but there is a breakdown of sports and exercise – including some activities that have little to do with sport, such as cycling and dancing. The tables tell us that participation in sport is heavily biased towards younger males, and that within the category of sporting activity, competitive sports scarcely feature as contributing to exercise.

The report states, rightly, that “there is abundant evidence that regular activity is related to a reduced incidence of chronic conditions of particular concern in Scotland, such as cardiovascular disease, obesity, and type 2 diabetes.” However, the report also claims that “sports and exercise are important elements of any physical activity strategy, and major events such as the 2012 London Olympics and 2014 Glasgow Commonwealth Games are considered valuable ways of promoting physical activity in the population.” There is no good evidence to support that contention. Athletics, and indeed competitive sport in general, make very little contribution to the physical activity of the population. If we want people to engage more in physical activity, we ought to be promoting walking, gardening and cycling.

Additional note, 20th January 2019:  An article in New Scientist (edition of 19.1.2019) explains that calorie consumption has a surprisingly limited association with exercise.  As obesity is only weakly related to physical activity, physical activity is only weakly related to sport, and elite sport is only weakly related to participation in sport, it’s unsurprising that obesity has no visible relationship to major sporting events.

Public sector pay

The government expresses concern that public sector pay has risen above private sector pay. That is only to be expected. Whenever services are commissioned from the private and voluntary sectors, lower-paid workers are moved out of the public sector. Those who are left behind are the senior managers whose task is to commission services, and their pay tends to be higher than those of the employees who have been transferred out. This has been the policy of both Labour and Conservative governments for more than twenty years.

Abiraterone

The press reports, again, that patients are being denied life-enhancing drugs to save money.  In this case, the issue centres partly from the draft guidance prepared by NICE on Abiraterone, and partly on the impression in Scotland that the drug in question may be partly responsible for the unexpectedly long survival of a convicted murderer.

NICE gets a terrible press, but the work they do is exemplary. The consideration given by the committee is, as ever, consistently careful, thorough and balanced. Their brief was to review  

  • Overall survival
  • Progression-free survival
  • Response rate
  • Prostate specific antigen (PSA) response
  • Adverse effects of treatment, and
  • Health-related quality of life.

There is a case for Abiteraterone.  It does extend survival by about four months – roughly a third more than without the drug – and it seems to have fewer side effects than the existing drugs. However, the benefits are still limited, and the drug is hugely expensive.

This specific example seems to fall into a category discussed in a debate in the British Medical Journal in 2009 (31st January). Adrian Towse, the director of the Office of Health Economics, argued that the public were generally willing to support payments that were double what NICE was allowing for. The NICE thresholds were typically a cost of £20-30,000 for each QALY (a year of valued life), a figure that has been raised for end of life treatments; the public would support £30-70,000. Against that, James Raftery argued that the thresholds should be lower, because they force health trusts to take resources away from other, more effective treatments. The cost of Abiraterone falls in the region of £53,800 to £63,200 for each QALY.  

There is beyond that a common problem: the evidence in this case is almost entirely supplied by the drug’s manufacturer. Manufacturers have only a limited window during which they can market a drug before patents expire; spending time to run all the tests, and in particular to identify the groups best able to benefit, is not always consistent with their financial interests. It is not clear whether Abiraterone does extend survival more than all the alternatives, because the manufacturer has not yet made all the necessary comparisons. If the gaps could be closed, the case for approving the drug would be stronger.

Freedom of Information requests

Various Freedom of Information requests have been made recently to the Department for Work and Pensions about the mandatory imposition of work experience. This process has produced copies of the guidance issued by the DWP, including a recent revision removing instructions to JCP staff to mandate claimants. There is a full set of documents covering mandatory experience here and a list of related FoI requests and their returns at http://helpmeinvestigate.com/welfare/ .

I’ve also posted this information to the Social Policy discussion list at JISCmail, because it relates to a long-standing debate in Social Policy. The Social Policy Association published guidelines over two years ago which stated that researchers have to obtain the consent of participants, and allow them to withdraw from the research. I think the guidelines are misconceived, and FoI requests are an illustration of why I think so. First, some information is public, not private; it is not under the control of the people who happen to know it. Second, Social Policy has an important critical function, and that does not depend on the consent of government. Those who are interested in the arguments might want to look at my piece on “Research without Consent” in Social Research Update or the criticism of the SPA guidelines that Dave Byrne and I made in Policy World.