Avoiding a hierarchy of equalities

There was a major general election announcement over the weekend that focused on mental health policy. Whilst this is great news in itself, I’ll bet someone, somewhere, has written that there should be an equivalent for people with learning disabilities, or for people with sensory impairments, or for carers, or for older people with x condition etc. etc.

This is not where we want to be.

As I’ve written before:

Whilst there are arguments which could be made for each [impairment group requiring something separate], to my mind there is no overarching framework within which all of them hang together. There is no agenda around which all people with a commitment to disability rights and equality for all disabled people can coalesce.

In the absence of an overarching disability rights and equality framework, what we end up with is a hierarchy. In such a hierarchy, mental health is currently doing (relatively) ok, but learning disability less so. And if learning disability ends up with a new cross-government strategy then what about… and so on. Goodness knows what happens if you’re a person who happens to tick more than one box.

The point can also be extended to other equality groups: there is common cause, for example, in closing the gender pay gap and the disability employment and pay gaps (as exemplified by the nonsense suggestion that people with learning disabilities should be paid below the national minimum wage).

Insteaf of separate policies we should be calling for a reignited overarching disability equality strategy, which builds on the heritage of the Life Chances report, the Independent Living Strategy and Fulfilling Potential. Underneath this could easily lie dedicated action plans and analysis that relate to particular impairment groups, and so still taking account of the specific barriers some groups face. Such a strategy would clearly link to a general equalities strategy, showing common cause across all protected characteristics. This should all be backed by a strong central government presence, including through a significantly rejuvenated Office for Disability Issues, through the Government Equalities Office or, perhaps, through proper resourcing and respect for the Equality & Human Rights Commission.

By avoiding a hierarchy of equalities, the common cause of everyone will be improved.

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Hypothecation, hypothetically speaking

Would you be prepared to pay an extra 1p in income tax if it was guaranteed to go to the NHS?

Pls RT to increase the sample size#VoteNHS

— NHS Million (@NHSMillion) May 6, 2017

This won’t be the last question about hypothecated taxes in this general election, nor in elections for the rest of time.

Hypothecation is the process of assigning tax revenues to specific areas. The debate about it has a long history in the UK – see this House of Commons Library research paper (pdf).

In health, a little nugget to consider is that National Insurance raises roughly how much the health service costs. NI receipts in 2016/17 were £126bn and the NHS budget for 2016/17 was £120bn. But if you follow where those NI receipts go, I’d be surprised if they go directly to the NHS.

There’s a nice paper from the World Health Organisation (pdf) that I’d recommend reading on this thorny topic. I like it because it digs behind the economics of hypothecation and examines the reasons for and against it. The reasons given for hypothecation include:

• Trust
• Transparency
• Public support
• Protecting resources.

You can therefore see why @NHSMillion would be keen on hypothecation – particularly looking at that last point: the lack of trust that appears to exist is exactly why people want to protect NHS resources.

This said, I’ve never been a fan of hypothecation. Whilst it would be foolish to argue against trust and transparency in particular, I’m not sure you need hypothecation to ensure trust and transparency. The other cons of hypothecation also point to my reluctance to embrace it. They include:

• Undermining solidarity
• Exemption from review
• Inappropriate funding levels
• Tying the hands of government.

It’s coincidence that funding levels and NI receipts are roughly similar in health. But controlling for this,  my worry with hypothecation is that we quickly undermine solidarity for tax revenues and public services. Hypothecation opens the possibility of people saying “yes, I’ll pay tax for x” and so potentially “no, I won’t pay tax for y.” I fear it would exacerbate what we already see in areas like welfare support and social care.

Whilst hypothecation isn’t an answer, I think it at least helps us pose the right sorts of questions: how do we ensure transparency in how public money is spent, how do we debate the right balance between different types of services, and how do we build trust between those who make these decisions on a day-to-day basis on behalf of the electorate.

Three pieces on Future Labour

I continue to struggle in the aftermath of Brexit.

Not, necessarily, just because of the result – it was a long time coming, and perhaps has woken the individualised and consumerised winners of the last 30 years from their torpor.

But also because of where it leaves Labour – stuck, somewhere, fighting the battles of the 20^th century.

I’m not sufficiently informed, connected or clever enough to know where the Labour party should go and to offer a view on where the destination is and how to get there. There’s also little I feel I can personally do to help steer or jump on board with where Labour should go. I do know, though, that (1) I have been a Labour party member since 1998; (2) even now, I’m not sure if there is another “party” I would want to belong to; and (3) the current party cannot be or do what it should.

I therefore continue to look for the best diagnoses of Labour’s current situation in order to understand it as well as I can, and for glimpses of what the future could be and how Labour might plot a course to get there.

Three pieces I’ve found particularly useful of late are from John Harris, Neal Lawson and Anthony Painter. Here they are on where we are:

1. John Harris in the Guardian:

As with the centre-left parties across Europe in the same predicament, Labour is a 20th-century party adrift in a new reality. Its social foundations – the unions, heavy industry, the nonconformist church, a deference to the big state that has long evaporated – are either in deep retreat or have vanished completely.

2. Neal Lawson on Open Democracy

Everything that once made Labour strong and the 1945 settlement possible; a unified working class, a bureaucratic system of governance (Fordism), memories of the war and the depression and the existence of the Soviet Union as a global counter to capitalism had gone. They have been replaced by forces inimical to traditional social democracy, namely financialisation, globalsiation, individualization and consumerisation. Labour, I argued, was a ‘Kodak party in a world of instagram’.

3. Anthony Painter:

The point is that the working class – Labour’s alleged base – is irrevocably split. Moreover, there is no going back now. The schism is permanent.

And here they are on where to go.

John Harris:

The left’s future will involve many Labour people, but also some in the Greens, Liberal Democrats – even one-nation Tories – and thousands of people with no affiliation at all. However it is organised, it will have to start with an understanding of the fact this is a crisis of democracy, and support a change to the electoral system and a move towards multi-party politics.

Neal Lawson:

[We] must recognize that no single party or movement has all the answers. The future will not be imposed but negotiated. Most immediately it needs to be negotiated by all the progressive parties in a Progressive Alliance to try and counter the massive shift to the right we are experiencing.

Anthony Painter:

Instead of expending energy on saving Labour, something entirely new is needed. Labour was a movement before it was a party and so should whatever replaces it from within or without be.

This movement would seek to build from the cities out. It would embrace pluralist progressives – from the remain labour working classes to social liberals. It would be a movement that sought to build the right networks and platforms for social justice.

A movement of citizens that would over time seek elected office, it would espouse democratic, economic and social reform…

This movement would demand a new social contract; the current state fails to support the reality of modern economic life and leaves families and whole communities locked in insecurity and poverty. These would be new platforms for economic security such as Basic Income and social mobility. Security and mobility would be seen as dependent upon one another- holding no one back, leaving no one behind.

It’s person-centred, Jim – but not as we know it

We all have our favourite “I can’t believe that actually happened” stories in social care.

Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).

It would be funny if it weren’t so normal.

But we hear variations of this all the time, summarised in the line:

Of course what I do is person-centred care – it always has been

If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).

This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:

1. Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
2. Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
3. Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
4. Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions

Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.

It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.

What politics isn’t

In recent posts we’ve noted what politics currently isn’t: neither civil nor balanced.

Chris Dillow also notes here what politics isn’t, through the eyes of people who are interested in what passes for politics:

Most of those who claim to take an interest in it are not really interested in how to govern the public sphere: if they were there’d much more interest in the social sciences. Instead, they’re mere spectators in a wrestling match who are booing baddies and cheering goodies.

I cheered – well, sighed – reading this.

This begs the question: what is politics?

We’ll need to go back to Plato, Aristotle, Hobbes and Locke to get started on this. At least, though, we’re asking the right question.

 

Obama’s civility in a polarised world

We wrote last week about political polarisation, through which we include two different-but-related things: (1) exaggerated debate about public services being the norm; and (2) the role of interest groups in polarising politics.

Then up popped a video comparing Barack Obama and Donald Trump’s ways of dealing with hecklers:

This echoed David Brooks’s piece reflecting on the civility of Obama’s presidency, and the fact we’ll miss it when it’s gone:

Obama radiates an ethos of integrity, humanity, good manners and elegance that I’m beginning to miss, and that I suspect we will all miss a bit, regardless of who replaces him.

What I note about Obama is that he always plays the ball and not the player. He engages in the debate and doesn’t resort to name-calling, ad hominem  attacks or the tone someone employs.

As you would hope, he engages at the upper scales of the Hierarchy of Disagreement:

DH0: Name-calling

DH1: Ad Hominem

DH2: Responding to tone

DH3: Contradiction

DH4 Counterargument

DH5: Refutation

DH6: Refuting the central point

Our polarised political debate means Obama’s civility stands out. Perhaps we can restore civility and try to engage in what people are saying and why, rather than who they are and how they say it?

Interest groups and political polarisation: outside the Bell Curve

There is a great passage in Francis Fukuyama’s Political Order and Political Decay (pp.481-484) that reminded me of what we’ve talked about here before: the exaggerated nature of political debate.

To summarise our thoughts (in the context of public services):

• People’s experiences of public services follow a Normal Distribution
• Although most people’s experiences are average or thereabouts, the experiences and examples we hear most about are, almost by definition, unusual
• Politicians, organisations (from whatever sector) and the media most often talk about the very best or the very worst that public services have to offer
• The very rare is what drives most activity in public services.

It’s this difference between the ends and the middle of the Normal Distribution that creates the problem in the space of people’s expectations of public services: The gap between what the Normal Distribution says our experience is most likely to be (95% of people will get an average service) and what we think our experience will be – the space represented by newspaper headlines and political rhetoric – leads to expectations that, in reality, can very rarely be met.

Fukuyama’s example relates to interest groups within the political economy, and it is a compelling explanation of why our political debate feels so polarised (in the equivalent way to why feelings about our public services are so polarised).

By way of background, Fukuyama first notes Mancur Olson’s negative portrayal of interest groups, in which Olson feels they operate only to extract benefits for themselves. This itself would be fine, except for the fact the general public can’t organise as effectively as relatively small interest groups, resulting in a “steady diversion of energy” into activities that only benefit the interest groups.

Fukuyama then summarises de Tocqueville’s more positive take on interest groups, in which it’s argued they are “schools for democracy” and teach private individuals the skills of coming together for public purposes.

Somewhere between the two is James Madison, whose view of interest groups was that, even if you don’t agree with the ends a particular interesting group is after, the fact there are so many of them would prevent any one group from dominating. Echoing how a free market operates, this pluralist approach to interest groups means they’d all interact to produce an overall good for the public.

What, though, is the reality? Fukuyama comes to the same conclusion we do about the exaggerated nature of public policy – interest groups polarise politics.

Image via Fanpop

Fukuyama gets to this conclusion by drawing on arguments from E.E. Scattschneider and Olson as follows:

• Political outcomes rarely follow from political preferences. Because there’s generally a low level of political awareness and participation amongst the population as a whole, decisions are actually taken by smaller groups of organised interests
• What compounds this is that not all interest groups are equally capable of organising themselves
• Those that are capable of organising are much more motivated to do so: they may feel more strongly or have more clearly defined positions they need to “defend” compared to weakly-held views or less well-defined positions
• As a result, “politics is defined by well-organised activists, whether in parties or government, the media, or lobbying and interest groups” and there is an “intrinsic overrepresentation of narrow interests”
• As a result we do not get compromise positions; instead we have polarisation and deadlocked politics.

It’s this that leads to the nonsense we see on Question Time each week, or “debates” where a presenter simply pits one viewpoint’s representative against another’s. It’s frustrating, and actually not at all representative of what the vast majority of people think.

Whilst political debate therefore operates mainly in these exaggerated positions at the margins, so it will be that people will disengage because of the seeming irrelevance of the debates to people’s everyday thoughts and beliefs.

Social care council tax precept: the beginnings of an opportunity?

The distribution of revenue raised for each council per head by the social care precept (Source: Richard Humphries at the King’s Fund)

First, some facts on where we are with local government and social care spending:

• Local government saw a 37% real-terms cut in government funding between 2010/11 and 2015/16 (NAO (pdf), executive summary)
• Adult social care expenditure fell by 8.7% in real terms between 2010/11 and 2014/15 (NAO (pdf), para 1.15)
• There has been a corresponding fall in social care activity in all areas of social care: homecare, day care, nursing care and residential care (between 2008/09 and 2013/14 – when data is available) (NAO (pdf), figure 4)
• Net local government spending per person (excluding public health, education, police and fire services) has been reduced by 23.4% between 2009/10 to 2014/15 (IFS (pdf), table 2.1)

Second, the effects of the social care precept. (Recall that the council tax precept for social care was introduced in the 2015 Spending Review, and is the ability of local government to raise council tax by up to 2%, as long as it is spent on social care.)

• LGA analysis suggests the council tax precept for social care would raise £400million in 2016/17, but only if all 152 local authorities used the precept in full
• The average Band D taxpayer would see an average rise of £24 in their council tax bill if the precept were used in full in 2016/17 (LGA)
• (The LGA has previously estimated that the social care funding gap would grow by at least £700 million in 2016/17. The introduction of the National Living Wage will cost councils at least £340 million in 2016/17 on top of this gap)
• Though the Treasury thinks the social care precept will raise £2billion by 2019/20, the King’s Fund notes the precept will (a) widen the gap in provision between richer and poorer areas, and (b) raise at most only £800m a year.

It’s hardly grounds for optimism is it?

And yet, I find myself wondering if there are reasons for hope in the social care precept? I suggest this for two reasons:

1. By saying that social care costs can be met by a centrally-enabled (general) tax, it feels to me that the government has set a precedent for funding social care through general taxation. This has not been an option government has realistically considered before, though there are plenty of ways general taxes can be levied and used (see, for example, pp.31-37 of the final report of the Barker Commission (pdf))
2. People will notice if their council tax bills rise. They’ll probably not appreciate it, and will want to know why their bills have gone up by an average of £24 for social care alone. We know that the general public has very little awareness of how social care is funded (see Chapter 2 of Ipsos Mori’s research for the Dilnot Commission (pdf)), so this therefore represents a communications opportunity that could begin to put social care (and how it is funded) on a par with the NHS in terms of public awareness.

It’s not much to go on, but the ability to make the case for adequate and sustainable funding for social care needs all the help it can get. The social care precept itself is neither adequate nor sustainable; but it might be the beginnings of an opportunity.

Another cross-party commission on health and social care?

Andy Cowper is most probably right that there won’t be another cross-party commission on health and social care:

A cross-party funding commission on health and social care might get traction if funding issues represented an imminent and significant political challenge to the Government.

Thanks to The Fixed Term Parliaments Act and the tacit, uncivil war within the Labour Party, this does not seem likely.

Andy also makes another vital point: the Treasury doesn’t think there is an NHS financial crisis, let alone one that can be fixed by investing more in social care.

(As an aside, can someone explain to me why ex-Ministers seem to be more proactive in a policy area than they were when actually Minister for the relevant portfolio? This, of course, is a rhetorical question, but doesn’t make the situation any less frustrating.)

 

Scooby Doo and the human reasons reform doesn’t happen

Image via Variety.com

Francis Fukuyuma noted 4 reasons why political reform happens:

1. Reform is a profoundly political process, not a technical one
2. The political coalition favouring reform has to be based on groups that do not have a strong stake in the existing system
3. While government reform reflects the material interests of the parties involved, ideas are critical in shaping how individuals see their interests
4. Reform takes a great deal of time.

Humans are a significant (actually, the only) reason these reforms don’t happen – we can see this in, for example, the lack of speed with which any public service reform happens.

Why are we like this? Fukuyama notes:

Human nature has provided us with a suite of emotions that encourage rule or norm following that is independent of the norm’s rationality. Sometimes… we follow rules simply because they are old and traditional. We are instinctively conformist and look around at our fellows for guidelines to our own behaviour.

Instead of reason, human behaviour is grounded in emotion and resulting biases (pace Kahnemann) like pride or shame.

Such human behaviour aggregates to institutions, and there are two main reasons institutions don’t adapt either.

The first is because they’re made up of humans, who follow rules for reasons that aren’t rational – see above!

The second is that institutions contain groups who have a vested interest in keeping things as they are:

Political institutions develop as new social groups emerge and challenge the existing equilibrium. If successful institutional development occurs, the rules of the system change and the former outsiders become insiders.

This is encouraging for those who seek and are successful in change.

As the institutions update themselves, though, so we have to be wary about the new elites within them:

But then the insiders acquire a stake in the new system and henceforth act to defend the new status quo. Because they are insiders, they can use their superior access to information and resources to manipulate the rules in their favour.

As each baddie in Scooby Doo notes they’d have gotten away with it if it weren’t for those pesky kids, so we’d achieve every public policy aim we could ever wish for if it weren’t for those pesky humans.