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

Michael Sandel: “The energy of the Brexiteers and Trump is born of the failure of elites”

The political philosopher on markets, morality and globalisation.

Jason Cowley: Shall we begin with Brexit? It’s very close here at the moment: the Remain side had big leads in the polls but it’s narrowed considerably since the conversation moved on to immigration, porous borders and freedom of movement of migrant workers within the EU. What forces are driving the desire for Brexit?

Michael Sandel: As an outside observer, I don’t feel it’s for me to offer a personal view about how Britain should vote. I think there are really two questions. One is whether Brexit would be good for Europe and the other is the question of whether it would be good for Britain. It seems to me that for Britain to remain in the EU would be a good thing for Europe, but whether it’s a good thing for Britain is something that’s for British voters to decide.

A big part of the debate has been about economics – jobs and trade and prosperity – but my hunch is that voters will decide less on economics than on culture and ­questions of identity and belonging.

JC Superficially, the United Kingdom seems a becalmed society, but we’re experiencing eruptions. We had the Scottish referendum in 2014, and we almost saw the break-up of the British state. Now we’re having a referendum on whether we should continue to be a member of the European Union. Why are there so many unsettled questions? Why are the people of the United Kingdom so restive?

MS I think the restiveness that you describe reflects a broader disquiet with democracy that we see in most democracies around the world today. There is a widespread frustration with politics, with politicians and with established political parties. This is for a couple of reasons; one of them is that citizens are rightly frustrated with the empty terms of public discourse in most democracies. Politics for the most part fails to address the big questions that matter most and that citizens care about: what makes for a just society, questions about the common good, questions about the role of markets, and about what it means to be a citizen. A second source of the frustration is the sense that people feel less and less in control of the forces that govern their lives. And the project of democratic self-government seems to be slipping from our grasp. This accounts for the rise of anti-establishment political movements and parties throughout Europe and in the US.

JC One of the key slogans of the Brexiteers is to regain control. Why does this resonate with so many? And are you somewhat sympathetic to that line of argument?
MS Well, I do think it resonates deeply. And I see this not only in Britain, I see this in the American political campaign, and I see it looking at the rise of anti-establishment parties throughout Europe. A theme running through these various political movements is taking back control, restoring control over the forces that govern our lives and giving people a voice.
As to whether I have some sympathy for this sentiment, I do. I don’t have sympathy for many of the actual political forms that it takes.

One of the biggest failures of the last generation of mainstream parties has been the failure to take seriously and to speak directly to people’s aspiration to feel that they have some meaningful say in shaping the forces that govern their lives. And this is partly a question of democracy: what does democracy actually mean in practice? It’s also closely related to a question of culture and identity. Because a sense of disempowerment is partly a sense that the project of self-government has failed. When it’s connected to borders, the desire to reassert control over borders, it also shows the close connection between a sense of disempowerment and a sense that people’s identities are under siege.

A large constituency of working-class voters feel that not only has the economy left them behind, but so has the culture, that the sources of their dignity, the dignity of labour, have been eroded and mocked by developments with globalisation, the rise of finance, the attention that is lavished by parties across the political spectrum on economic and financial elites, the technocratic emphasis of the established political parties. I think we’ve seen this tendency unfold over the last generation. Much of the energy animating the Brexit sentiment is born of this failure of elites, this failure of established political parties.

JC One particularly notable trend is the failure of mainstream social-democratic parties across Europe – the Labour Party included. Many people who might once have been inspired by or supported the centre left are now attracted by populist movements of both left and right. So why is social democracy failing?

MS Social democracy is in desperate need of reinvigoration, because it has over the past several decades lost its moral and civic energy and purpose. It’s become a largely managerial and technocratic orientation to politics. It’s lost its ability to inspire working people, and its vision, its moral and civic vision, has faltered. So for two generations after the Second World War, social democracy did have an animating vision, which was to create and to deepen and to articulate welfare states, and to moderate and provide a counterbalance to the power of unfettered market capitalism.

This was the raison d’être of social democracy, and it was connected to a larger purpose, which was to empower those who were not at the top of the class system, to empower working people and ordinary men and women, and also to nurture a sense of solidarity and an understanding of citizenship that enabled the entire society to say we are all in this together. But over the past, well, three or four decades, this sense of purpose has been lost, and I think it begins with the Ronald Reagan/Margaret Thatcher era.

JC You mean the neoliberal turn at the end of the 1970s – the advent of what you have called “market triumphalism”?
MS Right. It began there. But even when Reagan and Thatcher passed from the political scene, and were succeeded by the centre-left political leaders – Bill Clinton in the US, Tony Blair in Britain, Gerhard Schröder in Germany – these leaders did not challenge the fundamental assumption underlying the market faith of the Reagan/Thatcher years. They moderated, but consolidated the faith, the assumption that markets are the primary instrument for achieving the public good. And as a result, the centre left managed to regain political office but failed to reimagine the mission and purpose of social democracy, which ­became empty and obsolete. This remains an unfinished project.

JC Unfinished even after the financial crisis, when this was considered by many on the left to be a potential 
social-democratic moment?

MS That’s right, and I think many of us expected that the financial crisis would mark the end of an era of unqualified embrace of the market faith and the beginning of new debate about what should be the role and reach of markets in a good society. What happened, sadly, is that the financial crisis came and, although we did have some debate about regulatory reform, it was a rather narrowly cast debate. We have not yet had the more fundamental debate about what should be the role of markets in a good society. As a result, social democracy has not only lost the argument, it has failed to articulate a vision of a just society; it’s failed to articulate a conception of democracy as self-government. And so it is understandable that its traditional constituencies in working-class and middle-class communities lost confidence that social-democratic parties could be the vehicle either for a renewed sense of community and ­mutual responsibility or for collective democratic projects.

JC Is it also because trust has been lost in the state – because of the economic failures of the mid-to-late 1970s, the unravelling of the postwar consensus, stagflation and so on?

MS I think that has contributed to a loss of confidence in the state but I think a further source of lost confidence in the state is that, traditionally the democratic state has as one of its primary purposes to be a vehicle for self-government, to enable citizens to have some meaningful say in how they are governed. Whereas today the state seems more an obstacle to meaningful political participation and self-government than a vehicle for it. Any revival of social democracy would require not only an articulation of a conception of a just society, but also forms of political participation that could renew the democratic promise.

That’s as important as articulating a conception of a just society, working out institutions and civic practices that could revitalise the project of democracy as a vehicle for self-government. The existing state fails to do that and I think when people 
look to the European Union they also feel that it is not a vehicle for democratic self-government. So I think both the nation state and the European Union are seen to have failed in this regard.

JC So where does this leave us? I guess it leaves us in the UK approaching Brexit?
MS Where it leaves us is with a potent backlash. And it’s a backlash that is understandable. I think it’s a mistake to view the backlash – and it finds expression in the ways that we’ve been discussing – simply as people suddenly turning inward and against immigrants as if this were simply a matter of mindless bigotry by people, benighted people, who are ungenerous. It’s important for people who make the case for Remain to be able to offer a conception of Europe that could begin to address this unanswered hunger for meaningful self-government, for having a voice.

JC What about the EU as a social market with its own social standards and rules? Is that potentially progressive? It can impose certain transnational legislation on sovereign governments from outside that benefits workers.

MS It’s potentially progressive in the policy outcomes but that is not enough. A regulatory state, however effective and desirable its social regulations may be, is insufficient to win people’s allegiance unless the regulatory process is connected to a democratic process with which people identify as citizens who have a voice, who have a say.

It’s desirable to have the EU promulgate social regulations that moderate market forces and protect workers and protect the environment, protect health and safety. All of that’s good but it’s insufficient and I don’t think it can be supported politically unless it makes people feel they’re not being dictated to by faceless bureaucrats from Brussels. Even if those faceless bureaucrats promulgate very good social legislation, people want a voice, people want a say, people want a more robust democratic system. It’s a mistake to neglect that.

JC More generally, can free-market globalisation be tamed? And could we be entering an era of more protectionist economics? Consider the rhetoric of Trump.

MS I have no sympathy for Trump’s politics but I do think that his success reflects the failure of established parties and the elites in both parties to speak to the sense of disempowerment that we see in much of the middle class. The major parties have failed to speak to these questions. What Trump really appeals to is the sense of much of the working class that not only has the economy left them behind, but the culture no longer respects work and labour.

This is connected to the enormous rewards that in recent decades have been lavished on Wall Street and those who work in the financial industry, the growing financialisation of the American economy, and the decline of manufacturing and of work in the traditional sense. There is also the sense that not only have jobs been lost through various trade agreements and technological developments, but the economic benefits associated with those agreements and those technologies have not gone to the middle class or to the working class but to those at the very top. That’s the sense of injustice; but more than that, the fact that the nature of political parties – I’m speaking about those in the US – have become, since the time of the Clinton years, heavily dependent on both sides, Democrats and Repub­licans, on the financial industry for campaign contributions.

JC One thinks of the Clinton family’s relationship with Goldman Sachs, for instance.

MS Well, there you have an example of how the Democratic Party has become so Wall Street-friendly that it has largely ceased to be an effective counterweight to the power of big money in politics or to the financial industry and its influence in politics. And this is why Bernie Sanders was able, though he will not win the nomination, to have far more success than anyone imagined. He was originally thought to be a fringe candidate who would maybe get 5, 10 per cent of the vote. And yet he fought Hillary Clinton almost to a draw in many of the Democratic primaries. No one would have imagined that.

The mainstream of the Democratic Party had so embraced the financial industry that it was unable to provide an effective counterweight when it came to the financial crisis or to the aftermath, the regulatory debate. And oddly enough, Trump from the right and Bernie Sanders from the left have a good deal of overlap. They’ve both been critical of free-trade agreements that benefit multinational corporations and the financial industry but haven’t in practice helped workers.

Bernie Sanders has been a big critic of the role of money in politics, and Trump, though he’s a billionaire, also appeals to the anger about money in politics, when, at least during the primaries, he was able to claim that he was paying his own campaign costs and not depending on Wall Street. Despite their different ideological direction, they are both tapping in to the frustration that we’ve seen reflecting the failure of the mainstream parties.

JC What are the limits to markets? And what is the alternative to market triumphalism, especially when moderate social democracy is in crisis?

MS The only way of reining in the uncritical embrace of markets is to revitalise public discourse by engaging in questions of values more directly. Social democracy has to become less managerial and technocratic and has to return to its roots in a kind of moral and civic critique of the excesses of capitalism. At the level of public philosophy or ideology it has to work out a conception of a just society, it has to work out a conception of the common good, it has to work out a conception of moral and civic education as it relates to democracy and ­empowerment. That’s a big project and it hasn’t yet been realised by any contemporary social-democratic party.

A revitalised social-democratic response to the power of markets would also try to come up with institutions for meaningful self-government – forms of participatory democracy in an age of globalisation, where power seems to flow to transnational institutions and forms of association. It’s important also to find ways to promote participatory democracy. This requires political imagination and political courage. It’s a long-term project that remains as a challenge, but until we make some progress in that bigger challenge, I think that democratic politics will still be vulnerable to the backlash that we’re witnessing, with Brexit in Britain, some of the populist political movements in Europe, and Trump in the United States.

There is an alternative – but the alternative is to go beyond the managerial, technocratic approach to politics that has characterised the established parties and the elites, to reconnect with big questions that people care about.

Jason Cowley is editor of the New Statesman. He has been the editor of Granta, a senior editor at the Observer and a staff writer at the Times.

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