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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A multitude of rivals

Unless Donald Trump is able to master geopolitical complexity, the trouble in the Middle East will get far worse.

Well, who’d have thought it? Another popular insurgency in the series that started in Tunis in late 2010. The gift that keeps on giving. Only this time it has hit the United States, to the bemusement of those who like their liberal internationalism neat and any populist revolutions a long way from home. The same people who misread the Arab uprisings of 2011 and continue to believe magically that movements based on the word of God will embrace tolerance and inclusivity seem shocked that some Americans have decided to have an uprising of their own.

None of this will be lost on the leaders or people of the Middle East. My guess is they will be a lot less shocked than commentators in the US and Europe are. After all, the blurring of business and politics, the instrumentalisation of identity, ambiguity about where the public good ends and personal advantage begins and an often casual attitude to facts are characteristic of the politics of the region. More fundamentally, relations between states in the Middle East and North Africa are transactional; most significant trade flows are in commodities; and conflict within and between states is endemic. The region politically looks far more like the Hobbesian world of early-modern Europe than it does the Kantian dream of the European Union. Donald Trump talks like a mercantilist: Barack Obama talks like a Rawlsian idealist. Most Arab, Israeli or Iranian leaders are more comfortable with the former than the latter.

Indeed, Obama’s own eloquence has counted against him. His Cairo speech of 2009 in retrospect looks like a cruel illusion, one of Auden’s clever hopes more than the proclamation of a new ethical order, as many wanted to think at the time. It was unbacked by practical policies or even sustained attention. The moral reset never happened. What followed instead was disorder: the public disavowal of the Egyptian president Hosni Mubarak in 2011, an apparent assumption that the politics of Islamist revelation were consistent with ­liberal pluralism and – when the error was realised – grudging acquiescence in the counter-revolution and increasing exasperation with the result.

The Iran nuclear deal may or may not prove to be as great an achievement as its supporters claim. However, the self-congratulatory attempt to sell it to the Gulf states with an odd mixture of scolding and exhortation merely alienated them. It wasn’t that they didn’t understand the weight of Iran and the desirability of a negotiated settlement: they did and do. They simply didn’t want to be treated like the most disruptive students at the back of an International Relations
101 remedial class.

So the standard by which they – and Sisi’s Egypt, Erdogan’s Turkey, Khamenei’s Iran and everyone else in the Middle East – will judge the incoming administration is not the one that socially liberal and politically idealistic Americans and Europeans will use. They won’t worry so much about free trade: oil and gas will find their own markets. They’re OK with going bilateral: multilateralism only gives them headaches, which was why the Iranians liked dealing principally with the US over their nuclear programme, why Cairo is flirting with Moscow and why the choice between Algiers and Rabat is always going to be binary. They’re good at negotiating deals. If that’s how the new guys in Washington want to proceed, that’s fine by them.

The energy producers will like a renewed emphasis on industry: the Rust Belt isn’t coming back but it doesn’t hurt to pretend that it might. They will still worry about the resilience of fracking but that was going to be the case anyway. If new areas for energy production are opened up in Alaska, the Gulf of Mexico and elsewhere, then that adds to the downward pressure on prices. However, it will take a while to start producing significant quantities of oil and gas from the new fields. And at least it reflects an enthusiasm for hydrocarbons rather than waves, wind or water.

The real areas of uncertainty are elsewhere. All the states of the region want their concerns to be taken more seriously than anyone else’s. That will entail having opinions on the conflicts between them – and sometimes taking sides. That may be more straightforward with Israel than has been the case under Obama. Trump on the campaign trail suggested he will tilt much more towards Israel than Obama has done, not just on issues such as settlements and the status of Jerusalem but on hardcore security solutions to the challenges of Palestinian nationalism, Islamist extremism and the more generalised threat from Iran and its proxies.

Saudi Arabia, meanwhile, will be closely watching what position the new administration takes on the recently passed Justice Against Sponsors of Terrorism Act, which will allow families and victims of the 9/11 attacks to pursue a civil lawsuit against Riyadh. The kingdom will also monitor how belligerent campaign statements about Islamic State and its ideological cousins might play out in power, and how compliant the US approach will continue to be on the Iran nuclear agreement. A unilateral abandonment of US commitments is unlikely: the deal is a Security Council matter, many other states have equity, and they are only too eager to do business, as we have seen for some time with China and now more recent activity by France’s Total and German and British business delegations to Tehran.

It is also not clear that being justifiably suspicious of Iran automatically makes you a friend of Riyadh. Trump has done business with the kingdom in the past but has also criticised Saudi over-reliance on the US for its defence. And hardliners in Tehran would probably be undisturbed if Washington walked away. A resumption of enrichment would hardly look like a victory for the new US administration, especially if European energy firms were the wider beneficiaries.

Trump has displayed a startlingly nativist and isolationist side during the presidential campaign. The test of this will include Iraq, where the US has a highly effective strategy at the moment that involves significant political and military commitments; Syria, where it does not; and Yemen, where it had one but mislaid it. And even in Iraq, the real test will be sustaining an effective political strategy after the fall of Mosul. This will happen on Trump’s watch, not Obama’s.

In the end, the Trump administration will come up against a fundamental and enduring feature of Middle Eastern politics: everything is connected. In business, if one golf-course project is a bust, you can always find another that isn’t. In the international diplomacy of the Middle East, that won’t work. It may be unfair, but US presidents are supposed to do something when 400,000 people die in a civil war somewhere and Iranian-backed militias colonise zombified states. If you recognise Jerusalem as the undivided capital of Israel, you alienate not just Palestinians, but most other Arabs and Muslims and many Europeans. But you need them if you want a proper contain, distrust and verify policy on Iran. You also give movements such as al-Qaeda, Islamic State and Hezbollah – one of the biggest criminal enterprises on the planet – a perfect alibi. If you think the answer on Syria is to let Bashar al-Assad reassert control with the help of the Russians and the Iranians, you need to be able to persuade those Arabs and Turks who back the largely Sunni opposition to stop doing so. You can’t do that if they think you don’t respect them or their interests. And you might want to ask yourself if making nice with Putin over Aleppo could lead him to think you wouldn’t mind if he helped himself to Tallinn, Riga and Vilnius while he was at it.

Full disclosure: I’m a signed-up member of the international relations blob. So I would say this, wouldn’t I? But here goes anyway. The trick is managing political complexity. That isn’t something for which the president-elect is famous, and wasn’t a notable feature of the campaign debates. It may be that his choices of secretary of state, national security adviser, CIA director, and indeed energy and treasury secretaries, will reflect an understanding of the importance in a complicated and uncertain world of competent, experienced figures, and of the central role of the US president in supporting the liberal international order created after the Second World War that underpinned the US rise to dominance. I hope so. If this order collapses it won’t be just because US voters elected Donald Trump. It will be because of demographic, economic and sociological shifts across the globe.

As far as the Middle East and North Africa go, the dilemma is not so much Thucydidean (rising powers challenging established rivals) as Machiavellian: a multitude of rivals with shifting allegiances challenging each other for primacy. We have lacked a common understanding and collective purpose for at least a decade. Determined and smart US political engagement across the region is essential to rebuilding both. Without that we won’t see a new and stable order created by the regional states: we will see more entropy. US partners in the region will feel both abandoned and licensed. US enemies will feel liberated. In both cases, the costs of hedging with other external powers – Turkey, Russia, China, India – will decrease dramatically. Good luck with the aftermath of all that. However bad the region may look today, “the worst is not. So long as we can say: ‘This is the worst.’”

John Jenkins is a former British ambassador to Saudi Arabia, Libya, Iraq, Syria and Burma. He also served as a senior diplomat in Jerusalem, Abu Dhabi, Kuwait and Malaysia, and as director for the Middle East and North Africa at the Foreign Office in London. He is now the executive director (Middle East) of the International Institute for Strategic Studies, and is based in Bahrain

This article first appeared in the 17 November 2016 issue of the New Statesman, Trump world