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Author Archives: Tina Hearn

The erosion of democracy in healthcare policy

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Tina Hearn turns to William Temple for the principles that must be prioritised in healthcare policymaking if we are to truly ‘build back better’.

‘History may not repeat itself, but it can rhyme’ (Mark Twain).

Before the end of the Second World War, William Temple and aligned proponents argued there was a pressing need to ‘build back better’ in all policy areas, including welfare—a position eventually embraced by all parties. The trope of ‘build back better’ echoes again across the polity today, so, yes, history has rhymed around the broad need for policy reform. However, today, there are also profound dissonances with regard to Temple’s policy principles.

To inform the project of building back better, Temple crafted a series of principles in Christianity and Social Order, as well as in his broader writing. One of Temple’s key principles was the Christian idea of fellowship in the form of democratisation, which he claimed should inform all areas of socioeconomic life. He argued that democracy and its constituent principles—such as representation, responsiveness, and accountability—‘deepens and intensifies personal fellowship’ giving ‘the highest value to the personality and personal relationships of all citizens in the community’ (Church Looks Forward, pp. 142-143). Temple viewed de-democratisation as corrosive of human personality, fellowship, and broader society.

However, many contemporary policy developments are highly dissonant with Temple’s principles. This is evident across a range of contemporary policy developments, which will profoundly shape welfare policy futures, including the Health and Care Bill which has just received its second reading in parliament.

A widespread concern about the Health and Care Bill, is that it embodies a range of de-democratising policy principles and provisions. For example, as the British Medical Association (BMA) has noted, the Bill contains provisions which afford increased powers to the secretary of state, arguing that it is ‘totally wrong for Government to have the power to abolish arm’s length bodies without due scrutiny, approve or reject Integrated Care System (ICS) chairs, or interfere with local decisions’. The BMA has also expressed concerns about the threat of private health providers having a formal seat on ICS boards, the new decision-making bodies, and wielding influence over commissioning decisions. This is already the case in Bath and Somerset where Virgin Care has a seat on the local ICS and is leading on the Integrated Care Record Initiative.

Temple argued that the ‘private sector will inevitably put private sector interests first. If we want to put the public interest first, we must so organise our life that those who are chosen for their concern with and qualification to judge the public interest are in positions of control’ (Church Looks Forward, p. 110)—a view supported by evidence on private provider companies. People who receive care and local communities are also important stakeholders here. However, the Bill has no specific provisions for patient or community representation on the new Health Boards. The Bill thus exhibits tendencies towards amplifying centralisation and sectoral commercial interests rather than democratisation. 

The scope for outsourcing health services to the private sector in the Bill, arguably poses further democratic risks and erodes accountability. This is not new: the significant expansion of outsourced health care since the 2012 Lansley Act has created multiple democratic fault lines across the NHS. A lack of transparency, regulation, and accountability around outsourced provision has been widely noted both prior to and during COVID. This is a worrying trend, amplified by the diminution of transparency through repeated appeals by the government to ‘commercial confidentiality’ to justify non-disclosure of a range of procurement and contractual information. There are also concerning indications that there are moves towards reducing the level of regulation still further, with a regulatory review contracted out to KPMG.

The anti-democratic implications of the increase in health service provision exports to private sector providers also needs to be considered alongside the strong anti-democratic tendencies which increasingly prevail across the economy. For example, the representation and participation of labour in discussion and decision making has been significantly eroded. The exercise of monopoly power in the form of the dominance of large corporations has increased. And there has been an increasing number of service contracts issued to companies such as private equity, whose primary drivers are shareholder returns rather than public good—a trend echoed in social care services.

It should be noted that the Health and Care Bill forms just one plank of the government’s proposals to ‘build back better’ for the future. This brief review of some of the provisions of the new Health and Care Bill indicate that the provisions and principles of the Health and Care Bill run counter to, and so undermine, Temple’s appeal to fellowship and democracy. More worrying still, these tendencies are also evident in policy initiatives and proposals to reform further areas of the welfare state, including education, social security, and housing—and indeed extend beyond welfare reform, for example, in the Crime, Policing and Courts Bill and proposals to reform judicial review. Of course, there are different views around what principles should inform any process of ‘building back better’. However, current developments do not sit comfortably with Temple’s principles, nor with a wide range of positions on the political spectrum, including the professed libertarian position of the current administration (for whom, logically, a centralising, controlling state is an anathema).

Much of what could be done to improve health policy such that it rhymes more effectively with Temple’s principles of fellowship and democracy could be achieved through annulling the policy dynamics outlined above. Of course, democratising initiatives could be extended far beyond this: equalities legislation and social purpose provisions could be firmly integrated into procurement processes, prioritising public-interest-oriented service provision; service principles could be developed through deeper and wider consultation; top-down management processes could be replaced with stakeholder management models; and the list could, and should, go on. As Temple presciently noted, without due attention to clear policy principles there is a risk of welfare policies emerging that have strong, centralising, anti-democratic inflections—the direction in which we clearly seem to be heading.

Dedicated to Prof Kailash Chand OBE FRCGP, who died on 26th July 2021.

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Liberty and response-ability in the time of coronavirus

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Tina Hearn, Associate Research Fellow at the William Temple Foundation, proposes that policies for the coronavirus crisis should embody the concept of ‘response-ability’.

The coronavirus outbreak has already been deeply traumatising for many families, communities and nations across the globe. It has been particularly so for people with chronic health conditions, compromised immune systems, life-threatening illnesses and those who have children, family members, friends and colleagues who are vulnerable. My twitter feed currently reverberates with expressions of powerlessness and fear. For example:

‘For the first time today I accepted that maybe I won’t make it through all this… I have a compromised immune system, I have a chronic illness, I am the person in the “well we all have to get used to losing someone before their time”… I am scared and so sad.’

Urging people to take personal responsibility (hand-washing and self-isolating) has been a primary focus of government policy to date—an emphasis which has considerably amplified people’s fears. And these fears are completely understandable in the context of many people’s lived experiences. For example, around 15 million people in the UK have disabilities, chronic or life-threatening conditions. Many disabled and chronically ill people depend on social security for their income. But, given that social security has been frozen since 2016, people often have insufficient money for food on a weekly basis, let alone the ability to take on the responsibility to stock up, self-isolate and protect themselves. This is also the case for many of the 14 million people in the UK who are now in poverty. Indeed, many foodbanks are fast running short of supplies.

Many older people, who are more likely to have underlying health problems, have resonant fears. Observing the situation in Italy, where medics have had to make choices about who receives treatment, older people have not been a priority. (It is worth highlighting that Italy has twice as many intensive care beds as the NHS.) In the UK, government austerity policies have involved significant constraints on health service funding and deep cuts to social care budgets over the past ten years, both of which can be life-saving resources for older people. Older people’s fears have been further reinforced by media commentators who routinely devalue older people, often in a quite shocking manner. For example, the Telegraph journalist Jeremy Warner stated this week that economically the coronavirus “might even prove mildly beneficial in the long term by disproportionately culling elderly dependents”.

Given this context, we need to question government policies which revolve around prioritising personal responsibility. In the face of profound material privations, this advice rings pretty hollow for many disabled, chronically ill and older people. How can this almost exclusive policy emphasis on the exercise of personal responsibility be accounted for in relation to people who simply do not have the resources to exercise that responsibility? That is a very big question, and a wide range of explanations have been offered.

Some of those explanations are based on observation. For example, Conservative MP Nadine Dorries argued there is a tendency for ministers to be totally out of touch with the life experiences of ordinary people, capturing this in her observation that ministers are often “posh boys who don’t know the price of milk”. Other explanations have focused on how current policies reflect many of the government’s core ideological principles, which include the following examples.

First, there is a far greater priority placed upon the welfare of the wealthy and the markets than the welfare of ordinary people. For example, the lion’s share of alleviating the burden of the deficit arising from bailing out the banks following the crisis of 2007-8 has been borne, not by the banks themselves, but by the social security budget, and hence by people with chronic health conditions and disabilities—thus significantly depleting people’s ability to exercise personal responsibility.

Second, there has been antipathy towards, and a move away from, policy interventions that are framed in terms of community, such as social care. Instead, there has been an increasing valorisation of, and move towards, policies which shift costs and responsibilities from the state onto the individual. As Maurizio Lazzarato puts it, there is a move to ‘responsibilise’ the individual. Yet in the UK context of high levels of inequality relative to other countries, this increasingly diminishes people’s ability to exercise responsibility.

Third, and a related point, the government has a tendency to prioritise liberty, and a very thin, legal and contractual conception of liberty, which it diametrically counterposes to security—through, say, government welfare resource provisions. However, as Raymond Plant and indeed William Temple in his ‘Christianity and the Social Order’ emphasise, liberty and security are not in tension, but rather intimately entangled. Liberty requires security in the form of resources, such as adequate income, shelter, care and health services. Only with such security do we have the liberty and therefore the ability to exercise responsibility meaningfully.

The analysis above could be developed at length. However, the key point is that this more developed conception of liberty and responsibility suggests that, in the context of the current coronavirus crisis, the government and policy-makers need to move away from embracing and promoting a thin conception of liberty and responsibility and frame their policies with reference to a conception of liberty and ‘response-ability’—in short, developing policies which enhance the abilities of people to be able to respond and stay safe.

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What sort of society do we wish to become? – Borges’ forking pathways

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Associate Research Fellow Tina Hearn steps back from the current political turmoil to consider the wider context of our debate and how the conversation needs to be broadened.

Jorge Luis Borges’ evocative essay ‘The Garden of Forking Pathways’ portrays life as a series of forking paths; each ‘fork’ signifies a point at which questions are raised and a range of alternative pathways are variously illuminated. Sometimes, these questions are intimate. What should I do? What would be an ethical way forward for our team? At other times, questions have broader purchase. What sort of society are we?  And what sort of society do we want to become?

At a forking pathway in the first half of the 20th century, William Temple and his contemporaries confronted the question ‘what sort of society are we?’ head on. It was a question which emerged from an emotionally raw, war-torn and fragile country, founded upon a profoundly asymmetrical and corrosive economic system that was broadly self-serving regarding its own welfare and security. Few economic enterprises directly engaged with the ethical questions of the security and welfare of their workers, families and communities. Hence, the insecurities and indignities of destitution, poverty, unemployment, casualised and insecure work, low pay and the ever-present fear of the workhouse were widespread. These conditions provoked Temple to contend in his essay ‘Christianity and the Social Order’ that:

“[Economic concerns] occupied a greater place in the ordering of life and the shaping of individual ambitions than in any previous period […] (men) ceased to ask what was the purpose of this vast mass of production. It tended to be an end in itself. It was no longer subordinated to the general scheme of a complete human life in which it should be a part.”

Temple also engaged with the question ‘what sort of society do we wish to become?’. Various ways forward were illuminated at the time, including laissez-faire marketisation, populism and authoritarian nationalism. Temple signposted an alternative pathway in ‘Christianity and the Social Order’, in which he mapped the key co-ordinates of a social infrastructure for achieving security and wellbeing for all, subsequently crystallised in the Beveridge Report. This infrastructure, in particular the social security system, which Beveridge described as the linchpin of the whole system, was designed to counter-balance the vagaries of a deeply asymmetrical economic system such as widespread economic insecurity and lack. It was ultimately Temple and Beveridge’s pathway that was most brightly illuminated, and thus embraced, affording greater security and dignity for many people.

The question of ‘what sort of society do we wish to become?’ emerged again in sharp relief in the insecure socioeconomic context of the late 1970s and 1980s. The array of forking pathways at this juncture were unevenly illuminated. The path which won the day, recursively construed the needs and welfare of markets as paramount, and the post-war social welfare settlement and its role in ensuring broader human security and wellbeing as corrosive. Thus, markets were deregulated, corporate taxes were cut and the size of the state was constrained—a pathway which has broadly been followed for a significant part of the last 40 years. Following the financial crisis, however, these trends have been profoundly amplified. A trenchant programme of austerity has been implemented which has eroded our social infrastructure. In particular, our social security system has experienced the deepest cuts further amplifying socioeconomic insecurities and indignities.

Thus, 14 million people are now in poverty—more than half of whom are in work. The social security system has been restructured under the rubric of Universal Credit and payments frozen, resulting in rising numbers of evictions, homelessness, destitution and ballooning demands for emergency support from foodbanks. The Citizen’s Advice Bureau reports that many people dependent on social security are no longer able to afford sufficient food or pay their bills. Education bodies report that staff are having to provide food and other essentials for hungry children; health problems associated with poverty such as malnutrition are rising. Our social security system was described in the UN’s recent report on poverty in the UK as producing the “systematic immiseration of a significant part of the British population”.

Borges argued that history does not repeat itself, yet historical dynamics can certainly resonate and there are clear resonances between the landscape that Temple surveyed and the contemporary landscape to which we are now witness.

Today, there is little doubt that we are engaging with a series of Borges’ forking pathways, each of which, in different ways, engage with the questions ‘what sort of society are we?’ and ‘what sort of society do we want to become?’. These questions are perhaps inevitably inflected through the prism of Brexit and include issues such as the future welfare and security of our environment, our economy, and our political infrastructure. However, as Ruth Lister argues, as a broader society we seem to have developed an ‘art of ignoring the poor’ and so pathways which could engage with the profoundly important issues of human security and dignity largely remain obscured. As Borges notes, issues have to be effectively illuminated for a pathway to be both recognised and traversed. Thus, in the current febrile political atmosphere, there is arguably an urgent need for us all to contribute in our different ways to illuminating the fact that current understandings of ‘security’ need to be broadened and rendered much more inclusivist.

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