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

Show Hide image

What would a Trump presidency mean for the rest of the world?

It would be wrong to hope that either domestic or international checks and balances will constrain Trump abroad. Geopolitically, the result would be unpredictable – at best.

The conventional wisdom about Donald Trump runs something like this. Trump is a buffoon. His solutions to world problems are not policies at all, but merely a set of contrarian reflexes. They will soon be ­exposed in the next televised presidential debate against his rival Hillary Clinton, who put in a strong performance during the first round. He is, critics say, a mere pied piper whose “deplorable” followers suffer from false consciousness about their true economic interest. Trump’s election would be a disaster, the argument runs, but his policies will soon prove impracticable.

The conventional view is wrong. Although his personal behaviour is often clownish or boorish, and he has shown astonishing ignorance of some important international issues, Trump has a perfectly coherent world-view and strategy which are rooted in certain established American traditions, even if these are now largely defunct. Most of his followers know exactly what they are voting for and they are right to believe that he will deliver, or at least attempt to do so. As for the idea that a Trump presidency would be a disaster, that is completely wide of the mark. It is actually much worse than most people think. President Trump has the potential to be an unmitigated catastrophe – if not for the United States, then certainly for the rest of the world.

Far from taking a leap in the dark, Trump supporters know that they will be voting for a clearly defined package of domestic and foreign-political measures. With Trump, in ways that are not really true of his predecessors, or of Hillary Clinton, the two spheres cannot be usefully separated. He stands for the protection of American jobs at home, and therefore for a restrictive trade policy abroad. He wants to get tough on terrorism by having recourse to torture, in both the United States and the rest of the world. He wants to increase military spending. He wants to “put America first” and increase investment in schools and infrastructure in the United States, and therefore eschews “nation-building” abroad.

We should not assume that this is just rhetoric. First, because Trump has been saying all this, or much of it, for years in his writings and in off-the cuff statements. He is no mere opportunist. Second, because we know from scholarly analysis of recent campaigns, such as the one carried out by the former White House adviser and political scientist Steven Schrage, that presidential policies often quite closely track those advanced during the campaign. Third, because Trump emerges from the confluence of two long-dormant but now resurgent American political traditions: the blunt, early-19th-century appeal of Andrew Jackson to the “common man” and the protectionist isolationism that produced the Smoot-Hawley tariffs and the Charles Lindbergh of the 1930s.

When contemplating Trump, critics often focus on his domestic consequences. They foresee an empowering of white supremacist discourses and a surge in hate crimes, especially against Muslims. These are reasonable fears, but the threat Trump poses to politics within the United States is probably overstated. There will certainly be an increase in racial tension and other forms of unpleasantness, but American society is resilient, diverse and fundamentally decent, even if some of it is currently trying to prove the opposite. The US is not seriously at risk of lapsing into the kind of populist authoritarianism we see in many other parts of the world. Moreover, the nature of the American constitution is such that Trump will be very constrained in what he can do at home: by Congress, by the courts and various other checks and balances.

There are far fewer impediments, however, to presidential power in foreign policy. As so much of Trump’s domestic programme depends on what he does abroad, the rest of the world will be much more exposed to a Trump presidency than the Americans themselves.

Trump’s impact on the world will initially be a matter of style. He has shown himself to be misogynistic, vindictive, xenophobic and unafraid to trample on the feelings of veterans or the bereaved. This would be neither here nor there – tastes differ, after all – were it not that Trump’s personality will translate internationally into an instinctive rapport with other “outspoken” leaders such as Vladimir Putin in Russia, Recep Tayyip Erdogan in Turkey or Rodrigo Duterte in the Philippines. In the event of disagreement between them and Trump, we might expect a degree of vituperation on both sides in ways that are not compatible with the long-established dignity of the presidency of the United States.

Style will soon become substance. At best, a Trump presidency will lead to the “Berlusconification” of international politics, which will become extended reality-TV events, at least in so far as they relate to the United States. More seriously, his antics will empower and encourage a coarsening of the discourse between states and about world problems. Here, the contrast with Presidents George W Bush and especially Barack Obama, whatever one thinks of their policies, could not be sharper.

Trump’s style will matter in international politics for another reason. First, despite all his rhetoric about deal-making, where his business experience is considerable – and he has sometimes shown a capacity to compromise – he seems to have a very limited and belligerent idea of what constitutes a successful diplomatic negotiation. Rejecting notions of “win-win”, Trump views a political “deal” as the imposition of his will on the other side. “In the end,” he writes of one successful transaction in his bestselling book The Art of the Deal, “we won by wearing everyone else down.” It is therefore no surprise that he cleaves to an essentially mercantilist view of world trade in which, say, Japan’s gain is America’s loss. Given his severe anger management issues, the great danger is that a clever adversary will get under his skin, provoke outbursts, and either make a laughing stock of the greatest power on Earth or precipitate a confrontation.

Second, Trump favours a particularly intuitive style of decision-making. He has gone on record as saying that people “are surprised by how quickly I make big decisions, but I’ve learned to trust my instincts and not to overthink things”. Of course, it is true that international politics often requires leaders to make speedy decisions, yet it is deeply worrying to think what Trump’s instincts will lead to when he has the proverbial finger on the button. This problem has already been commented on by a phalanx of Republican national security experts, none of whom thinks he should be entrusted with the nuclear codes.

No reliance should be placed here on the restraining force of his advisers, or of the bureaucracy in the US state and defence departments. Trump has already signalled that he will not listen. When asked a few months ago to identify those he consulted most often on foreign affairs, he replied: “I’m speaking with myself, number one, because I have a very good brain and I’ve said a lot of things.” The foreign policy “team” he has produced during the campaign is the weakest and most obscure that anybody has encountered in living memory.



The essence of Donald Trump’s vision for the world is the revival of American national greatness. He wants to “make America great again”. “Americanism, not globalism, will be our credo,” he says. His slogan “America First” is an unashamed borrowing from the isolationist platform of the 1920s and 1930s.

By contrast with every single Democratic and Republican president since the Second World War, including George Bush, Jr, Trump rejects the international liberal order. In office, this will be reflected in his opposition to global human rights initiatives, whether that be the banning of torture, or collective action to help Syrian refugees (whom he sees not as victims but as an Islamist national security threat). He will ride roughshod over human rights sensitivities when building his wall with Mexico. On the environment, Trump is likely to abrogate the Paris accord on greenhouse-gas emissions and to press ahead with work on the disputed Keystone oil pipeline between Canada and the US, as well as other projects.

He may well also play fast and loose with the national debt, having suggested that he may not repay it or the interest in full. “I’ve borrowed knowing that you can pay back with discounts,” he explains, adding that “I would borrow knowing that if the economy crashed you could make a deal”. But he may find that his ability to bounce back no fewer than four times from business bankruptcy may not be a transferable skill.

The other area in which Trump plans to tear up the international rulebook, and here the parallels with his opposition to gun control are evident, is the field of nuclear non-proliferation. He has repeatedly welcomed the idea of a Saudi, or South Korean, or Japanese nuclear bomb. The thinking is that this will achieve a balance of terror, which will keep the peace better than costly American intervention.

Cumulatively, all this will cause considerable disruption. It will unravel many of the webs of international society carefully woven over the past six decades or so. It may well make the Korean Peninsula or the Gulf even more unsafe. It will certainly make life unpleasant for Mexico. And it will lead to the end of the United States acting as the world’s policeman. The US will step up the number of global snatch-squads in the war on terror, certainly, but will cease to exercise a general superintendence over the defence of democracy and human rights. No Iraqs, perhaps, but also no interventions in Bosnia or Kosovo. The worst, however, is yet to come.

At the heart of Trump’s revolt against the liberal order, undoubtedly, is economics. Reviving the national economy is essential to his vision of making America great again. Central to that project is a revision of the terms of trade. Trump is convinced that the US is getting a raw deal, not only from its enemies, but also – and most importantly – from its friends. He might well overturn the North American Free Trade Agreement, will probably disavow the Trans-Pacific Partnership, and is most unlikely to go through with the Transatlantic Trade and Investment Partnership, assuming it is not killed off first on the other side of the Atlantic. He would not be above leaving the World Trade Organisation altogether. Above all, Trump will take on China, which he accuses – with considerable justice – of currency manipulation and sharp practices. At the very least, he will instruct the US ­department of commerce to take cases against China and he may well embark on a full-scale trade war.

If Trump’s grand strategy will begin with economics and trade, it will not end there. His measures will unleash their own, essentially geopolitical dynamic. At the moment, the Chinese are contemplating the prospect of a Trump presidency with remarkable insouciance. They seem to regard him as one of their own, a man who will not bother them with human rights sermons, and with whom they can do business. In some ways they are right: he is one of them. That, however, is the problem. Trump shares their ­zero-sum view of the world, and he explicitly intends to prevail at their expense.




Nobody has ever looked inside the “black box” of an all-out trade confrontation between China and the United States. Even if one thinks – as this author does – that some form of reckoning with China is necessary, Trump is surely the man temperamentally least suited to lead it. His strategy may revive American manufacturing, but modern supply chains are such that China is inextricably stitched into the US industrial ecosystem in ways that could defy safe unravelling. Yet one thing is clear: China, which holds a huge chunk of the US federal debt, will bitterly resist any attempt to repudiate it. Moreover, if unplugged from the US market, particularly at a time of falling European demand, China will face vast economic dislocation and consequent internal unrest. One way or the other, the reaction to any such measures by the Americans will be violent, with a countdown to conflict comparable only to the one triggered by Franklin D Roosevelt’s decision in 1941 to freeze all Japanese assets in the US and impose an oil embargo on Japan.

Another arena where Trump will give the kaleidoscope an almighty kick is Europe. His hostility to the European Union – the principal instrument of the continental order hitherto strongly supported by the United States – is well documented. This will add yet another problem to the long list already confronting Brussels and the national governments. As if that weren’t bad enough, Trump will encourage the European “deplorables”: Alternative für Deutschland in Germany, Jobbik in Hungary and the French Front National. His xenophobia and authoritarian personality will chime with them; his protectionism may even resonate on the European left. He will therefore be much less isolated in Europe than many like to think.

Worse still, the example of a wall with Mexico may well inspire similar endeavours in Europe – in the Balkans and the Mediterranean (where some barrier is necessary to defend the external boundary of the Schengen passportless travel zone), but also in central Europe and perhaps even within the core of the EU, thus destroying free movement of people on mainland Europe. The period from 1989 to 2016 may become known as “the interwall era”. The walls will go up across Europe and we may not see them brought down again in our lifetime.

But the deadliest threat to European security is Trump’s attitude to Nato. He has repeatedly questioned whether the United States should continue to protect Europe, most of which fails to pay its agreed contribution to the common defence. Here – unlike in the cases of South Korea and Japan, which largely pay their way on defence – he has a point. It is negated, however, by his undisguised admiration for Putin, the single greatest threat to the stability of the European order. One of Trump’s top military ­advisers, Michael T Flynn, a retired general, is a Russia enthusiast. One of his most trusted former confidants, Paul Manafort, served as a long-term political consultant to the disgraced ex-president of Ukraine and Russian stooge Viktor Yanukovych. One of his few named foreign policy advisers, Carter Page, also has close links to Russia.

Everything points to a President Trump lifting sanctions on Putin before time and recognising Russia’s annexation of Crimea. He is also highly likely to undermine the value of Nato’s Article 5 guarantee of collective defence, which will place the Baltic and Black Sea states and Poland in the firing line. Yet he seems oblivious to this danger, largely because he does not take Russia seriously in economic terms. It is one of the many failings of his foreign policy, and a surprising one, given his general belligerence, that he
does not take other factors, such as ideology or raw military power, much into account.

Geopolitically, the results of all this are entirely unpredictable and could lead to a different global strategic balance. In effect, Europe will be left on its own to stand against Russia and defend Western values worldwide. Putin may be emboldened to take risks, in Ukraine, in eastern and northern Europe, and elsewhere. On the other hand, he may prefer to explore a strategic partnership with Trump. That will surely begin with a joint effort to support the Assad regime in Syria, and probably develop into an alliance against China. In that case, we will be in a genuinely tripolar or even quadripolar world, in which the relationship between the Russo-American alliance, the British-European confederation and the other Eastern dictatorship, China, will be one of unstable equidistance.




Finally, it would be wrong to hope that either domestic or international checks and balances will constrain Trump abroad. The executive will be bound to obey most of his orders in theory and probably all of them in practice. It is true that the military, the CIA and law-enforcement officers might, as the former National Security Agency and CIA director Michael Hayden has suggested, refuse to follow an “illegal” order. It is also possible that Congress might hold up international trade measures in so far as they relate to treaties. The EU may even be so appalled that it rallies in the face of Trump.

Yet this is wishful thinking. Crucial questions, such as whether to deliver on a Nato Article 5 guarantee in Europe, are matters to be decided by the executive alone, and for good reason. Moreover, Trump will have much of the United States behind him in making his initial foreign policy moves. Demand that the Europeans “pay up” for their own defence? Why not? Beat up on China’s protectionism? What’s not to like? As for Isis, even Homeland’s Peter Quinn thinks that the solution is to “pound Raqqa into a parking lot”. It would take superhuman moral and political courage to stop Trump early on. And with Europe, the idea that it will show resolve in the face of an external threat is, sadly, a sign of the triumph of hope over experience. Many Europeans, in fact, will cheer him on. At home and abroad, Trump will the harvest low-hanging fruit first, and then invest the capital gained in riskier enterprises. When he does really overstep the mark, it will be too late.

There is a very thin silver lining in all of this, at least for Britain: Trump is a known enthusiast for the United Kingdom. He has come out strongly against Scottish independence. He will almost certainly favour London over Brussels in trade matters. Above all, with him in the White House, Theresa May will be the only grown-up left among the major military powers of the West. The EU will almost certainly try to compensate for the loss of an interlocutor in Washington by moving closer to London. Britain will probably also benefit from an outflow of American “creatives” after a Trump victory – at least, of those for whom Canada isn’t far away enough. Britain may well also attract talent from around the world that would otherwise have gone to Silicon Valley or other centres of innovation in the United States.

In short, President Trump is likely to deliver a severe shock to both the US and the rest of the world. Although at home there are clear limits to what he can achieve, there are far fewer constraints abroad. There is little doubt, therefore, that the Americans, and probably the British, will survive Trump. The question is: will the rest of us?

Brendan Simms is an NS contributing writer. His latest book is “Britain’s Europe: a Thousand Years of Conflict and Co-operation” (Allen Lane)

This article first appeared in the 06 October 2016 issue of the New Statesman, Trump's triumph