Is Labour abolishing illness?

The new rules on incapacity benefit stake everything on a major gamble: that a large proportion of c

Incapacity benefit has become one of this year's favourite scare stories. Hardly a day passes without a new headline deploring its soaring costs and the rising numbers of claimants who get "something for nothing", at the expense of decent, hardworking taxpayers. We are told that we are footing an outrageously escalating bill for 2.4 million people, a million of whom shouldn't be on the benefit at all, and each successive work and pensions minister vows to be more ruthless than the last.

The true picture is somewhat different. The unreported version, which can be culled from Department for Work and Pensions (DWP) data, is that only 1.4 of the 2.4 million actually receive any payment, the rest get national insurance credits only, and numbers have been falling since 2003. The basic benefit is worth barely £3,000 a year. After two small rises in the first year there is no further increase, other than index-linking. All those who get the benefit have to pass a rigorous "personal capability assessment" (PCA) with doctors appointed by the DWP; and they can be re-examined at any time. The audited estimate of fraud is under 1 per cent - the lowest of any part of the social security system.

Nonetheless, the 2007 Welfare Reform Act is now being implemented across the country. It replaces support, as of right, for illness/disability (one of the planks of our rapidly disappearing welfare state) with a new, conditional employment and support allowance. Claimants are held on a basic allowance until it is confirmed that their capability for work is limited. This is determined by a "work capability assessment" tougher than the old PCA. Those deemed capable of one day returning to work (and the arbiters are health professionals rather than doctors) must engage in a series of "work-focused" interviews and activities. These include, among other things, "condition management", which in practice is likely to consist of group sessions loosely based on cognitive behavioural therapy. All this brings an additional slice of benefit that can, however, be cut for those who do not engage in it without "good cause" - a potential loss of 40 per cent of income. Ultimately, any whose capability for work remains limited through failing to follow medical advice, or "any prescribed rules of behaviour", face a period of disqualification. (A further provision of the act, to be piloted in nine areas, is that people served with Asbos - antisocial behaviour orders - can face cuts in their housing benefit for refusing local authority offers "to help address any problem behaviour".)

A main selling point of the reform was the great savings it would bring. It would staunch the outflow of benefits and get many people into jobs where they would pay tax and provide for their old age. This government's cherished goal is an employment rate of 80 per cent of the working-age population - though it is difficult to find any reasoned argument in support of this since our present rate of 75 per cent is, with Canada's, the highest in the world. The government accepts that employers must be paid to take on people with an illness record and, for the time being, it has pledged not to cut the benefits of existing claimants. Any immediate savings, therefore, can only come from bumping as many as possible off the benefit, shaving future benefit levels (already well in hand), and making it harder for newcomers to get it in the first place. Delivery is being farmed out to private agencies paid by results - which means, of course, the setting of targets. The next few years will be a bad time to have a crippling accident or succumb to a serious disease, particularly a psychiatric or neurological one that does not have obvious outward symptoms.

Blaming the "cheats"

The reform of incapacity benefit has been over ten years in the making, leaving in its wake a dense trail of commissioned reports. A curious thing about this voluminous material is how little information it contains on the actual health conditions for which benefit is paid. This is no accident, for the reformers long ago made up their minds that claimant numbers are too high, therefore a large proportion - usually put between a third and a half, but lately upped to 70 per cent in some quarters - must be spurious. An appeal to history is repeated like a mantra that, back in 1979, only 700,000 claimed the old sickness/invalidity benefits. Since then, money has been poured into the NHS while health care, living standards and longevity have improved beyond all expectations. People must be healthier, which proves that huge numbers are exploiting a slack and obsolete system. Who is to blame, apart from outright cheats? It can only be the self-indulgent, who fancy themselves sicker than they really are, and complacent GPs who let them think they are too ill to work.

Crucially, the reformers bracketed illness with disability. The disability lobby had long argued that "disability" was a discriminatory label imposed by society, and it was bent on removing the barriers to work that excluded those so labelled and kept them in poverty. But the bracketing brought confusions - for those with disabilities may be extremely fit (consider the disabled athlete), whereas the able-bodied can be extremely ill. More confusion arises with conditions such as "stress", "anxiety" and "chronic fatigue" that sound trivial. As for "back pain", how unreasonable is it to take time off sick for something best dealt with by a stiff upper lip and the odd aspirin? It is easy for those in good health to pooh-pooh such things, agreeing with the government that "Work is the best therapy".

The government's declared mission is to "liberate" claimants, to bring them into its "reformed, coherent welfare state for the 21st century". It seeks to overturn a culture based on the "medical model" of illness that allows them to "drift" on to long-term benefits without realising that "symptoms, feeling unwell, sickness and incapacity are not the same" - hence the appeal of cognitive behavioural therapy, which it understands as a treatment that will talk the sick into believing they can lead normal lives.

Doctors - so often the refuge of desperate people trying to find out what is wrong with them - should as far as possible be excluded from the process. Even those working for the DWP have opinions that are "unfounded, of limited value and counter-productive", while GPs are "unaware of the importance of work, the absence of which leads to depression, poor health, higher rates of suicide and mortality, poverty, and social exclusion". (The quotations are from a 2005 study from the Unum Provident Centre for Psychosocial and Disability Research at Cardiff University, whose ideas and rhetoric infuse the reform. Unum Provident is an American firm, the largest disability insurance company in the world, which is currently in litigation in different countries for refusing to pay out on some of its policies.) A private agency has now taken over the running of its first GP surgery here, and doctors dealing with disability living allowance are advised not to invite patients to explain how their condition affects them.

Features of the reform are familiar from other policy areas. First, a demonisation of a needy or vulnerable group, followed by a rebranding: so claimants become not even "clients" but "customers" (as in the just published "Commissioning Strategy" document); incapacity benefit becomes employment and support allowance; sick notes are redrafted for doctors to certify, not what patients can't but what they can do. Next come "partnerships", on an unchallenged assumption that the public sector has failed. The new system is farmed out to for-profit or non-profit-making agencies paid by results. This entails targets, and where targets are set, sanctions follow, for any who "fail to recover".

There are features of the new programme that look intelligent and humane, doubtless owing much to the efforts of the disability lobby. They include a longer and more flexible bridging period (and a back-to-work grant) between benefits and work, and a broader view of "work- focused" activities. The crunch will come with those described as not able or prepared to engage "because [of] the nature and severity of their health condition, or more a matter of attitudes, perceptions and expectations which may or may not be accurate . . . It is a question of what the claimant cannot do vs what they will not do."

For the reform stakes everything on a gamble: that a large proportion of claimants, present and to come, are fit enough to work. There seems no way of proving or disproving this, other than trying it out, at the risk of much waste of public money, and much personal grief. Deliberate rejection of the "medical model" deprives us of all we might have learned (from the wealth of data available) of the impact of illness on our society.

I have scratched my head long and hard over this reform (among other things sending out lengthy submissions to all concerned during the long consultation phase in 2005-2006) because so much in its theory and rhetoric contradicts my own experience: of chronically and seriously ill family members and friends, of several years as a Mind volunteer, and further years of peripheral involvement in action groups for chronic fatigue conditions. All this has indelibly impressed me with the courage of many who live with horrible complaints, the sheer hard work involved in their day-to-day coping, their relentless search for any amelioration, let alone cure, often at costs hard to spare from limited resources.

I have witnessed, too, and at close quarters, the hurt and stress of living difficult lives as people have to do, in a perpetual culture of disbelief and threat, where some of the most valiant are blamed for their conditions and conflated with the alleged "can't work, won't work" unemployed. For the message of the reform that comes across, for all its fashionable rhetoric, is that a person is valued only as a productive unit. Compassionate cases aside, those too ill to work are outside society and money spent on them is wasted. Sickness, disablement and inability to work have no place in a modern society - they can't and shouldn't be afforded.

No one pretends that illness is not a blight, imposing personal and social costs going far beyond the financial; but - pace the government - no one as yet knows how to remove it from the human condition. Why waste valuable time and resources on an ill-founded reform, when they could instead be used to further understanding of the real impact of illness on our society?

Alison Ravetz is a professor emeritus of Leeds Metropolitan University who writes on housing policy and welfare reform

This article first appeared in the 05 May 2008 issue of the New Statesman, High-street robbery

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The dark shadow

The Brexit proposal springs from panic and would certainly be terrible news for Britain’s economy – but it carries a threat even greater than that.

It cannot be said that the European ­Union is doing particularly well at this time. Its economic performance has been mostly terrible, with high unemployment and low economic expansion, and the political union itself is showing many signs of fragility. It is not hard to understand the temptation of many in Britain to call it a day and “go home”. And yet it would be a huge mistake for Britain to leave the EU. The losses would be great, and the gains quite puny. And the “home” to go back to no longer exists in the way it did when Britannia ruled the waves.

We live in a thoroughly interdependent world, nowhere more so than in Europe. The contemporary prosperity of Europe – and elsewhere, too – draws on extensive use of economic interconnections. While the unacceptable poverty and inequality that persist in much of the world, including Britain, certainly call for better-thought-out public engagement, the problems can be addressed better without getting isolated from the largest economy next door. The remarkable joint statement aired recently, by a surprisingly large number of British economists, of many different schools, that Brexit would be an enormous economic folly, reflects an appreciation of this glaring reality. Apart from trade and economic exchange with Europe itself, Britain is currently included in a large number of global agreements as a part of the European Union. Britain can do a lot – for itself and for Europe – to correct some of the big mistakes of European economic policies.

The Brexit-wallahs, if I may call the enthusiasts that (without, I hasten to add, any disrespect), sometimes respond to concerns of the kind I have been expressing with the reply that Britain can surely retain the economic interconnections with Europe, and through Europe, even without being in the European Union. “Isn’t that what Norway largely did?” Norway has certainly done well, and deserves credit for it. But the analogy does not really work, not just because Britain is a huge economy in a way Norway is not, but much more importantly because quitting is not at all the same thing as not joining. Britain’s extensive economic ties with Europe, and a great many EU trade agreements that go beyond Europe in the multilateral global economy, are well established now and disentanglement would be a very costly process – a challenge that Norway did not have to face.

But perhaps most importantly, it must be recognised that quitting is a big message to send to Europe and to the world: a message that Britain wants to move away from Europe. As four decades of economic studies have shown, signals can be dramatically important for economic relations. Conclusions will certainly be drawn on how dependable and friendly Britain can be taken to be. A jilted partner has more reason for angst than an unapproached suitor.

***

While the economic arguments against Brexit are strong, the political concerns are even stronger. The unification of Europe is an old dream. It is not quite as old as is sometimes suggested: the dream is not of classical antiquity. Alexander and other ancient Greeks were less interested in chatting with Angles, Saxons, Goths and Vikings than they were in conversing with the ancient Persians, Bactrians and Indians. Julius Caesar and Mark Antony identified more readily with the ancient Egyptians – already strongly linked with Greece and Rome – than with other Europeans located to the north of Rome and the west. But Europe went through successive waves of cultural and political integration, greatly helped by the powerful spread of Christianity, and by 1462 King George of Podebrady in Bohemia was talking about pan-European unity.

Many other invocations followed, and by the 18th century even George Washington wrote to the Marquis de Lafayette: “One day, on the model of the United States of America, a United States of Europe will come into being.”

It was, however, the sequence of the two world wars in the 20th century, with their vast shedding of European blood, that firmly established the urgency of political unity in Europe. As W H Auden wrote in early 1939, on the eve of the Second World War:

In the nightmare of the dark
All the dogs of Europe bark,
And the living nations wait,
Each sequestered in its hate . . .

His worst expectations found chilling confirmation in the years that followed.

The fear of a repeat of what Europeans had seen in these wars continued to haunt people. It is important in this context to ­appreciate that the movement for European unification began as a crusade for political unity, rather than for an economic union – not to mention a financial unification, or a common currency. None of the follies that make the economics of the European Union so problematic arose from that vision. The remedies that are needed (on which I have written elsewhere: see “What happened to Europe?”, the New Republic, 2 August 2012) would need policy changes and institutional reforms, but not any rejection of the idea behind a united Europe.

The birth of the European ­federalist movement was motivated strongly by the desire for political unity, free from self-destructive wars, as can be seen in the arguments presented in the Ventotene Declaration of 1941 and the Milan Declaration of 1943. There was, of course, no hostility to economic integration (and its merits were understood), but the priority was not on banking and currency, nor even on trade and exchange, but on peace and goodwill and a gradually evolving political and social integration. That political unification has fallen way behind the ill-thought-out financial moves is a sad fact. The EU’s policy priorities need to be scrutinised and reworked – a process to which Britain can contribute, and from which it can benefit along with other Europeans.

***

No wars, of course, will result from Brexit, yet that does not mean that the sense of rejection and distancing will have no adverse impact on the way Europeans see each other. That the dislike of having other Europeans settling in Britain is a major reason given in favour of Brexit – playing up the fear of “our” jobs, “our” economic opportunities being taken by “them” – makes this human distancing even more poignant. It is hard not to miss the recognition that this fear, exaggerated by dubious use of numbers, has been fanned politically by the enthusiasts for Brexit. And that adds to the intensification of relational adversity. Being “sequestered in hate” is a bit of a nightmare in its own right, even without the open violence which followed that terrible nightmare, shortly after Auden wrote his poem.

The EU did not create the idea of ­Europe, just as the idea of India was not a ­product of the nationalist movement (even though an otherwise brilliant European, Winston Churchill, failed to see any more unity in India than could be found around the Equator). The message of Brexit would have huge implications, given where the world is at this time. The Polish philosopher Leszek Koakowski has rightly asked, “If we would like the EU to be more than just a place for money temples of banks and the stock exchange, but also a place where material welfare is surrounded by art and is used to help the poor, if we want freedom of speech, which can be so easily misused to propagate lies and evil, as well as be used for inspiring works – then what is to be done?” When, at the end of the Second World War and after the defeat of Nazi Germany, Britain established its National Health Service and laid the foundations of a welfare state, it was inspired not merely by ideas originating in this country, but by thoughts that had sprung up across Europe, including the ideas of Kant and Marx and even Bismarck, in the country just defeated. There was no conflict between innovative British ideas and broader European thinking, nor between British and European identities (there is no reason for us to be incarcerated in one identity – one affiliation – per head).

The proposal of Brexit is born out of panic, and it is as important to see that the reasoning behind the panic is hasty and weak as it is to recognise that wisdom is rarely born of fright. In his Nexus Lecture, called “The Idea of Europe”, given a dozen years ago, George Steiner wondered about the prospects for Europe playing a leadership role in the pursuit of humanism in the world. He argued: “If it can purge itself of its own dark heritage, by confronting that heritage unflinchingly, the Europe of Montaigne and Erasmus, of Voltaire and Immanuel Kant may, once again, give guidance.” Brexit would certainly be a bad economic move, but the threat that it carries is very much larger than that.

Amartya Sen is Professor of Economics and Philosophy at Harvard and won the 1998 Nobel Prize in Economics.

This article first appeared in the 09 June 2016 issue of the New Statesman, A special issue on Britain in Europe