I know this is going to sound odd to Americans as there is no right to healthcare in the US, but I was recently at a meeting addressing the problems that exist both in provision of healthcare as well as social care in Britain, specifically in England and Wales. These discussions have arose due to several things which came to a head during the pandemic specifically the lack of government investment in the NHS, payments by NHS hospitals to private financing initiatives introduced by Labour under Blair and Brown (leading to indebtedness of NHS hospitals) and the privatisation of those parts of the NHS which were profitable. The creation of a private healthcare system existing in competition with the NHS not only drained resources (doctors, nurses) but since many doctors and medical professionals worked for both the NHS and private healthcare, it led to longer waiting lists for non-emergency procedures and decreased lack of access for many while increasing it for those that could afford private health care or got it from their jobs …
During the pandemic the sorry state of the healthcare system in Britain became evident; much of the healthcare system was devoted to dealing with the victims of the pandemic itself. Routine healthcare became harder to access and non-emergency surgeries were postponed leading to a massive backlog of procedures that while not “emergency surgeries” were important for people to have a lifestyle without pain. All emergency medical procedures like heart and lung diseases, cancer treatment, and dialysis continued but not the daily routine access to preventive healthcare that keeps us healthy.
While we do have a right to access healthcare in Britain in that healthcare is free at the point of demand, lack of government investment and the privatisation of the parts of healthcare that are profitable has led to a situation where these routine preventative treatment and surgeries that are deemed non-essential just couldn’t happen during the pandemic. The availability of hospital beds was insufficient to cope with a major pandemic, accessing our GPs became difficult to avoid spreading the virus and medical professionals of all types were called into support overburdened and besieged hospital staff.
However, waiting lists for non-emergency procedures done by the NHS had already existed prior to the pandemic and essentially the situation was exposed and worsened during the pandemic. The shift to private healthcare providers due to long waiting lists for procedures has been a problem which has existed in the UK; moreover, since the same doctors and surgeons work both for the NHS and private providers, the private sector has been a drain on the public health sector and the rationing of healthcare has undermined the NHS and indebted it. The resort to private healthcare providers by patients is a direct result of underinvestment by successive governments and privatisation. These processes of privatisation introduced serious inequalities in access to healthcare; so those that had the money to pay and those working for companies that provided access to private health care were essentially able to ”jump the queue” past those that could not afford to pay for their healthcare. Rather than reduce waiting periods in the NHS, the existence of the private healthcare sector increased lines (see the fact that the same doctors worked in both).
Social Care
The situation in adult social care is actually far worse and that derives from the fact that there is essentially no right to social care; there is a right to health care here in that you can get public health care free at the point of demand. However, access to government funded social care depends on income and wealth (assets) and the level of need which relates to impairment. As such there is no right to adult social care for the elderly and those with impairments. While I am using the terms “care” and “social care”, I am doing it because these are words that people know and use … I should be using support and assistance which is what disabled and elderly people primarily get, but this would only confuse the discussion and it is already complicated.
A short historical diversion
In order to understand the nature of care provision and the ability to receive support and assistance we need to discuss a very simple and basic thing – that is to whom the need for adult social care relates to; in others words who gets support and assistance when we discuss adult social? This is essentially people with impairments and the elderly. We can look a bit historically to see the roots of the problem we are facing and though things have changed substantially for the elderly (just the creation of pensions was a step forward) and the disabled (see the creation of disability benefits including the distinction of short-term versus long-term support), there are still issues that are embedded in the nature of the capitalist system.
One of the things that we find very early on in the early days of the capitalist system is a debate among economists and those working on social policy as to whether the poor have the right to subsistence unconditionally or whether they need to do something which makes them eligible for receiving their subsistence – this discussion relates to the notions of entitlement and eligibility respectively and weirdly we still see this criterion used today.
We see this discussion in Britain following the introduction of the 1795-7 Poor Law Amendment which attempted to deal with seasonal agricultural labour (which was still a dominant employer of labour)and the fact that the transformation towards a full market system did not guarantee that there was sufficient employment which guaranteed subsistence to workers who by no fault of their own were able to find paid employment the right to outdoor relief (that meant that they didn’t have to enter poor houses to get support) and this relief was tied to the size of the family and the price of wheat (the primary subsistence good).
What is very interesting is the discussions that are going on at this time is that there is a deliberate attempt to shift the responsibility for poverty away from the economic system being incapable of creating full employment towards that of blaming the unemployed for their poverty.
Commensurate with this discussion is a transformation in the determination of wages which shifts in the 1820-30s away from being based on the notion of subsistence and reproduction of the working class to the idea of a wage being determined by the supply and demand of capital used for the employment of
labour (that the fund for the employment of labour in relation to the number of people that needed employment) determined the wage that people got. It was not the fault of the system that people were poor, it was due to their own actions (e.g., having too many children, being drunk, lazy, indolent and dissolute) and as such all unemployment was voluntary.
While most people may have heard of Malthus’s Principle of Population and his Iron Law of Wages which of course blamed the poor for their own poverty (“people are poor because they have too many children”), what they probably do not know is that the first attack against the right of subsistence was done by Jeremy Bentham in 1797 as a direct response to the 1795-7 Poor Law Amendment called “Observations on the Poor Bill.”
This is a very important period of transition in the ideology that is economics and social policy and it shifts the responsibility for poverty away from the system itself and towards the actions (or inactions) of the poor themselves. As part of these discussions as to whether the poor have the right to subsistence and what they have to do to get it, the discussions of the rights of the poor relates to the belief that human beings not born to wealth must labour as their contribution to society; in exchange for that labour, they get a wage.
As part of that discussion, the question arises as to whether those that are unable to labour for their subsistence still have the right to subsistence. This whole discussion becomes what is known as the 1834 Poor Law Amendments or the New Poor Law.
So, if you were able-bodied, you had to work. A whole serious of quantitative and qualitative conditions were established determining whether you were able-bodied enough to work or whether you were entitled to support. If you were able-bodied and couldn’t find a job, you would have to enter the poorhouse to work there to contribute to society to get your subsistence. If you were unable to find employment to feed your family, you were forced to enter workhouses where you were put to work and all outdoor relief was eliminated. If you were not able-bodied and able to work, you were entitled to support from the state in the context of the workhouse (Jeremy Bentham who actually was the initiator of this discussion actually argued that even those with severe impairments could work in a workhouse as long as they were of sound mind) and insane asylums.
If all our contribution to society derives from work, what happens if we are unable to labour? What is the responsibility of society to you if you cannot contribute as a labourer? We can see the roots of institutionalisation of the impaired that are unable to work in this discussion as well as the treatment of orphans and the elderly. Because in the absence of family to support, you went to the workhouses, asylums and other institutions.
This may seem extraneous to our discussion of care, but it actually isn’t. What we can see above is a very clear example of the treatment for those who do not have the essential thing that enables one to survive in the capitalist system, the ability to labour. While they would not let you starve on the street, they also would not provide additional support for the family to care and assist the elderly who were unable to work due to injury and impairments, those with impairments, and young children too young to work. We have not even touched on the issue of care, but note how the whole discussion is couched in terms of subsistence but not support and assistance; all that is relevant is whether or not you are able to contribute through work and what you were entitled to if you weren’t able to do so given basic morality. Either the family could care for you or you were institutionalised, separated and treated as essentially a burden on the society.
The creation of pensions in Germany under Bismarck in the 1880s enabled the elderly to be independent from their families, easing the costs to families, and allowed for a turnover of generational labour. The creation of disability benefits in Germany was instituted at the same time. The creation of the welfare state further solidified a social safety net which was necessary as the capitalist economic system is prone to various forms of endemic crises started to shift the arguments that the poor were responsible for their poverty. However, the treatment of disabled people has often be based upon the view that they are a burden on society; we do not have to go to extreme of allowing forceable sterilisation of disabled people in the SCOTUS Decision of Buck vs Bell (1927) or the Nazis’s Aktion T4 programme which murdered disabled people. Even to this day with eugenics derided, disabled women still face pressure not to have children. Moreover, for decades we are once again in a period where those that are unable to work are viewed to be a burden on society and benefits and social security have been rationed and privatised.
The Benefits System
We need to separate two things before we go further. Short-term care caused by illness or an injury is a separate issue covered by national insurance payments. Longer term support and assistance for disabled people is the thorny issue that we are dealing with. Rising numbers of those accessing disability benefits led to an attempt to ration both the numbers receiving these benefits and assistance to cover the additional cost of being disabled. The introduction of assessment to provide proof of disability starts to be introduced for new people claiming disability benefit by Tony Blair. This has only gotten worse under successive Tory governments who actually outsourced the testing, interview and proof stage to private companies (who did not necessarily actually have medical knowledge and skills and whose jobs were to limit access to disability benefits) and of course this was extended to all those already in receipt of disability benefit. While previously Disability Living Allowance (DSA) which addressed the extra costs of being disabled to help with mobility and care took into account 3 different levels of mobility. The Independent Living Fund which was created to enable disabled people to live in communities rather than institutions was disbanded. Those who were caring for family members at home are eligible for Carer’s Allowance which is not related to wage levels at all and certainly do not compensate those that care for family members for the lack of a job. Moreover, if the person you are caring for is determined not to be disabled “enough” to get benefits, you lose the carer’s allowance even though you are still caring for them at home.
The most recent change in Government’s benefit policy was the introduction of Universal Credit (UC) in 2016 which was predicated on getting people back into employment as though those that were unemployed were work-shy and lazy. Employment Support Allowance (ESA) was introduced and you were then assessed on whether you were able to work or not and this would determine how much you get as benefit. This introduced a new tier of those receiving benefits called the Work Related Activity Group (WRAG) if they think you will be able to go to work. DLA was replaced by the Personal Independence Payment and mobility and level of care was reduced to two tiers in the new system. Invariably, since the point of UC was to get people back into work, the amount you could receive as benefit had to be lower than what you would earn as wages if you were in paid employment. There are more issues that were added but these are less relevant for disabled people unless they were put into the WRAG group. Since the level of benefits was lower on UC, many disabled people already on benefits stayed on legacy benefits (the older system) which were more generous to disabled people (this meant that when a £20 uplift was granted by the government to those on benefits during the Pandemic, that disabled people on legacy benefits were left behind).
The Health and Social Care Bill
Unfortunately, discussions of care are concerned with more of an issue of what must be provided, rather than what those who are elderly and with impairments want and need to be able to live independent lives. The voices of those who will receive support and assistance are rarely heard or heeded and neither are the voices of those actually working to provide support and assistance; those are two most important set of voices and yet they are routinely ignored. Rather than those people making decisions about what they want, policy makers put forward ideas on how to fund or ration these services.
The latest attempt to address the nightmare of the care system in Britain is the Government’s latest bill termed the Health and Social Care Bill which integrates health and social care (thereby medicalising social care rather than using the social model of disability) and raises funds for the coverage through increasing National Insurance (NI, this is social security in the US covering a state pension and entitlement towards certain welfare benefits). Moreover, most of the immediate funding will be going to the NHS and funding for social care will kick in in the near future. National Insurance is a Pay as you Earn system in which contributions are taken directly from wages if you are employed (or paid directly by you if you are self-employed; there are clearly no employer contributions for self-employed people) and contributions by employers. Increases in NI means that you will have less take home pay as contributions have been raised to fund the NHS and Social Care. Moreover, given the tendency in the previous decades to replace employees with hiring self-employed or sub-contractors, this means that employer contributions are reduced; in other words, there is an incentive for businesses to hire short-term subcontractors rather than employees.
The Crisis in Social Care (more like catastrophe)
What the bill also does besides integrating health and social care is to put a cap or limit on how much you have to spend for social care of £87,000. Access to publicly funded social care in Britain depend on assets and income; it is important to point out that if you have assets over £23,250 you are not eligible for publicly funded social care. This means testing means that the majority of those in need of social care have to fund it themselves. In stark term, this means is that those whose income and assets fall between £23,250 and 87,000 will have to pay for the costs of their care and will have little or no choice but to sell their homes (if they have them) in order to cover the costs of their social care.
Faced with rising costs and increasing demand for its services, the care system is unable to cope and is essentially failing, from King’s Fund :
“The number of people who need social care has risen over recent years, though this has not always been reflected in the number of people using care services. 1.9 million people requested support from their council last year, an increase of more than 100,000 since 2015/16. This rate of increase has in part been driven by demographic trends. People are living longer with multiple or complex needs and therefore might require short or long-term social care.
[…] However, demand for social care is not driven exclusively by an ageing population, the prevalence of disability among working-age adults has increased over recent years. The most recent data shows that the prevalence of disability among working-age adults is 19 per cent, up from 15 per cent in 2010/11. The same figure for older adults has remained static at around 44 per cent over the same period.