The illusion of independence

I think it’s an unspoken rule of politics that the person who claims to be unideological is the most ideological of all. Thus one of the central assertions of the newly formed “Independent Group” (IG) of British MPs is that while the blinkered automatons to their Right and Left see everything through an ideological prism, they, by contrast, do not pre-judge but look at every issue dispassionately and according to the evidence.

Thus when asked by Andrew Marr last Sunday whether the IG would support the renationalisation of the railways and the water industry, former Tory MP Heidi Allen replied: “My gut instinct is no but it needs to be based on evidence and, rather than just choosing ideological solutions, what will work and what we can learn from other countries.”

If you have that strange feeling of déjà vu, that’s because an insistence on ‘what works,’ as opposed to ideological prescriptions, was a staple of the New Labour years. Ministers could get way with claiming they judged everything according to the evidence because the evidence they relied on was produced by people whose ideological biases were so ‘baked in’ they thought they didn’t exist.

You’re only ill because you think you are

This can be seen most clearly in the story of the Work Capability Assessment (WCA), the tick box questionnaire that determines whether sick and disabled people can receive benefit and, if so, what conditions are attached. Judged in terms of the amount of misery it has generated – it was revealed in 2017 that the number of disabled claimants attempting suicide had doubled over the lifespan of the WCA – I think the assessment has no equal among post-war domestic government policies.

But its introduction was surrounded by mountains of evidence that it was the correct policy, medically and socially. In fact that it would be grossly unfair, it was claimed, to leave disabled people ‘parked’ on benefits and shut out from the health-giving qualities of work. In 2005, for example, the DWP commissioned a report called the Scientific and Conceptual Basis for Incapacity Benefit. Co-written by the department’s Chief Medical Officer, Dr Mansel Aylward, the paper recommended something called the biopsychosocial (BPS) model. This assumes that disability is caused in part by the disabled person’s attitudes. Illness was a belief, said the authors, and people could think themselves well.

They recommended, therefore, a “functional” non-medical assessment for all claimants on Incapacity Benefit, one that ignored diagnosis, prognosis and medical history. This became the WCA. The opinions of doctors weren’t mysteriously overlooked when the WCA came into being in 2008, they were deliberately ignored.

A year after the ‘Scientific and Conceptual Basis’ for the WCA was established, the DWP started funding a group of academics to run something known as the PACE trial, which compared the effectiveness of different treatments for Chronic Fatigue Syndrome or ME. The results from the trial were published in 2011 and were presented as demonstrating the visible success of BPS interventions such as Cognitive Behavioural Therapy. The then Conservative-Lib Dem government was miraculously bowled over by the evidence, with minister David Freud telling the House of Lords that “we have gone for the biopsychosocial model” which had “garnered very significant academic support”.

In fact, the research was very seriously flawed. An analysis by the Centre for Welfare Reform revealed that the supposedly “strict” standard for recovery was so loose that you could actually deteriorate and still be classed as having recovered. Another analysis of the whole BPS model concluded that it was “riddled with inconsistencies, misleading statements and ‘unevidenced’ claims”.

But so entrenched is the government’s faith in the ‘evidence’, that even Mansel Aylward, the man responsible for the adoption of the BPS model, admitting in 2012 that he now found it “unsatisfactory” and incapable of meeting the needs of disabled people, had no effect. The WCA steamroller, now over 10 years old, just continues on, oblivious of the collateral damage it causes.

I’m a banker so listen to me

But the WCA needed more than BPS philosophy – the idea that claimants were divided between real sufferers and malingerers – behind it to really fly. It also needed the evidence that there were legions of claimants who were ‘work ready’ and in fact, unjustly, left to rot on benefits. This was provided by David Freud, a millionaire and former investment banker, who despite admitting he knew nothing about welfare, produced the independent 2007 report Reducing Welfare, Increasing Opportunity: options for the future of welfare to work’, commissioned by Tony Blair just before he left office.

The ‘Freud Report’ was hugely influential – New Labour accepted its recommendations as did the Cameron government that followed. In fact, Cameron was so impressed he ennobled Freud and made him a junior minister in his government. The Freud Report achieved a ‘cross-party’ consensus. As a former Labour DWP minister put it in July 2010, “the Labour government’s regulations are now being tabled by a Tory minister who inspired them when he was a Labour adviser”.

Not only did Freud advocate using the private sector to conduct the assessments required to receive sickness benefit, and introducing sanctions, he also asserted that the 2.68 million people on Incapacity Benefit could and should be reduced by 1 million.

This number was subsequently cited endlessly ministers but, as geographer Danny Dorling pointed out, it was based on fiction. Freud “got his numbers” wrong by claiming the remarkable success of government ‘Pathways’ projects in getting Incapacity Benefit claimants into work could be replicated nationally. In fact, the success of the pathways projects was based on recent claimants only, not long-term ones.

 But this didn’t affect the Freud Report from becoming the lynchpin of government efforts to ‘reform’ the welfare state. The reason was not his academic rigour but who he was. As Dorling explained:

David’s report is titled Independent but was commissioned and published by the DWP. Independent no longer means independent. The point of independent reports to government and ministers is that they are not written by people who are independent of government but by folk whose lives and connections are intimately wound up in the machinery of government and elite civil society.

The fallacy of independence

Ironically it was Heidi Allen who confessed that, on becoming an MP, she was “staggered” that minister were not , in fact, experts in their field and MPs were handed “bits of paper” indicating what they should say to the media. But the fact that, in truth, they don’t know very much just reveals how reliant on outside evidence they are.

And that evidence is never unideological despite fervent claims to the contrary. While in 2007, a former investment banker was hired to produce a report arguing that sick and disabled benefit claimants needed to be reassessed into work, two years later the government commissioned two reports – Bischoff and Wigley – insisting the competitiveness of London as a financial centre had to be maintained at all costs. Group members and expert witnesses came overwhelmingly from the City of London. Finance, as one outside analysis pointed out, was reporting on “finance by telling stories about finance”. But all three, in eyes of the Westminster bubble, constituted ‘evidence’.

In truth, nothing is unideological and there is no such thing as pure, neutral evidence. Pretending you’re above the fray just reveals how deeply ensconced you are in its web – so much so that you don’t even notice.

Another Country

A review of ‘Cash not Care: the planned demolition of the UK welfare state’, by Mo Stewart

‘I want my country back!’ wailed Brexiters across the land during last year’s Referendum. But reading this book you realise that ‘your country’ – England, Britain and all parts thereof – was lost years ago and the capital of Belgium had nothing to do with the theft. Stewart painstakingly shows how hundreds of thousands of sick and disabled people have been prodded like cattle through a system deliberately designed to override the opinions of doctors and medical diagnosis, and leave them destitute. Currently, more than 2/3^rds of people who appeal to a tribunal against a decision of this system to rule them ‘fit for work’ are successful. The Work Capability Assessment, to give its proper name, betrays (in the words of one commentator) “a failure of compassion, unacknowledged incompetence and injustice on a massive scale”. And yet, far from acknowledging this tragedy the government wants to intensify it. No wonder one of the chapters of Stewart’s book is entitled, The Shame of Britain.

However, it is not this knowledge that imparts the strong sensation you are living in a foreign country. That unnerving sense creeps up on you through the realisation that the Work Capability Assessment is a replica of the non-medical assessment model of an American insurance corporation branded an ‘outlaw company’ for the way it has systematically denied ‘meritorious’ pay outs to sick and disabled claimants.  It was to Unum, labelled the second worst insurance company in America, and accused of running ‘disability denial factories’, that successive British governments turned in their desire to ‘reform’ the welfare state. You can read the whole shameful saga here.

But rather than summarise the story, I want to reflect on four things it says about the parlous state of this country in 2017:

1 We have a media problem

Stewart’s book is peppered with mounting anger that the story she is telling is unknown to the vast majority of the British people. “The entire national press, collectively,” she writes, “refused to expose to the British people the confirmed involvement of Unum (Provident) Insurance with the UK welfare reforms claims management since 1994.” There were isolated exceptions – Private Eye ­– for example. But almost exclusively it was left to minority publications, such as the Disability News Service, to tell the story. But, with the best will in the world, they have a limited market so “the vast majority of the abled bodied British people …. remained in total ignorance.” Academic research which lifted the lid of what was happening was only read by other academics or activists.

In short the steady undermining of Britain’s welfare state has been able to go on unimpeded because the media failed in its basic duty to inform the public of what was happening. It has been found that, among the public, estimates of incidence of benefit fraud range from 10 to 70% when, in reality, fraud stands at 0.3%. (I know that what the public means by fraud probably involves not really being ill as opposed to official definitions of fraud which involve outright deception but the gap is still enormous). On this and on other issues, media-formed perceptions are wildly inaccurate.

“We lack knowledge of the world beyond our direct experience … vast swathes of state-corporate activity are unreported,” Dan Hind wrote in The Return of the Public. The alternative media, though it has undoubtedly grown in recent years, cannot reach enough people to burst the bubble of the perceptions set by the mass media. The problem is exacerbated by the fact that public service media, such as the BBC, increasingly echo government priorities and see their role as reporting what ‘mainstream’ political currents, all claiming to represent the centre ground, agree to disagree about. The problem is the ‘centre-ground’ is a home for extremist political thinking and all three main political parties in this country have been utterly complicit in what has gone on. The perfect cover.

There is a justified air of fatalism about Stewart’s book – stemming from an awareness that, despite the moral imperative of its writing, it will likely not break through media fantasies. The same is true of any number of other urgent, seemingly hopeless situations – the nature of the environmental crisis, the likelihood of renewed financial breakdown – for example. Given the character of our media set-up, things will almost certainly get worse.

Improvement, by contrast, depends on changing the way reality ‘out there’, reality beyond day to day experience, is described. The existing media, not just tabloid newspapers, but also the BBC and liberal broadsheets, have a structural problem, and aren’t just guilty of moral failings. Dan Hind’s idea is for the public to decide, through a fund diverted from the BBC licence fee, what issues they want to see investigated. Thousands of journalists would be employed on researching subjects which the media would have a duty to report. The truth of what has happened to the British social security system could be one of those subjects. This may sound weak in the face of the problem but we have to accept – as Stewart’s research demonstrates – that the problem exists and that preaching ever more loudly to the converted is not going to dent it.

2 Our political parties have been thoroughly corporatized

“Sadly, these are policies that tarnish all three major political parties,” says academic Peter Beresford in the introduction to Stewart’s book. You couldn’t get the proverbial Rizla paper between New Labour and the Tories on welfare ‘reform’.   Way back in 1994 Unum were first appointed official government advisers by Conservative social security minister, Peter Lilley. When New Labour was elected, the desire for ‘active welfare’ intensified. Unum and Atos were both included in technical working groups that ironed out the details of the non-medical assessments that would determine who was eligible for disability benefits. “Approved doctors were trained in Unum’s approach to claims management”. A stringent ‘all work test’ was introduced, followed by Personal Capacity Assessment, described by the OECD as “one of the toughest in the world” – but evidently not tough enough. The 2008 Work Capability Assessment, defiantly focused on what ill people can do (such as raising their hands above their head in a tell-tale sign of work readiness), despite what ill-informed doctors might protest, was the culmination of this process.

When the Coalition entered government two years later, it made the WCA tougher still and carried through on applying it to existing Incapacity Benefit claimants – with the unwavering support of Labour, now in opposition.  The Conservatives now back “making workers pay into flexible savings accounts to fund their own sick pay” and enlarging the number of workers covered by employer ‘Group Income Protection’.

By coincidence, Unum has for years attempted to hawk both its individual and employer insurance products on the grounds that state benefits are becoming harder and harder to get.

But clearly welfare and disability is not the only area where corporations exert a decisive impact on UK government policies.  As the 2009 Alternative Report on UK Banking Reform noted, the City of London ‘has co-opted the leadership of both main political parties’. Not only did this monopolisation of views determine the climate of deregulation before the financial crisis, it also ensured that post-crisis nothing would be done to inhibit the ‘competitiveness’ of the UK as a financial centre.

Government policy has become thoroughly corporatized across the board. Corporate taxation heads inexorably downwards, subsidies go up and it is deemed as simply natural that public services are privatised or contracted out. Challengers to this state of affairs are branded left-wing populists but, in reality, they present isolated cases of politicians who haven’t been recuperated by this system and espouse policies that would have been considered quite tame and mainstream a few decades ago. They are not examples of dogmatic socialism against capitalist wisdom but pluralism in the face of a narrow corporate logic.

3 Chronically ill people are treated in a way that would shock us if it were meted out to the acutely ill

Britain can still muster outrage over the mistreatment of acutely ill people – those left on trolleys in hospital corridors or suffering prolonged abuse of care. But when it comes to mistreatment of the chronically ill – those affected by strokes, cancer, heart disease or ME for example – such empathy miraculously vanishes. At the root of the conscious cruelty inflicted by the WCA lies a stubborn conviction that these people aren’t really ill. According to the biopsychosocial model, the claims management ‘philosophy’ beloved of Unum and the Department for Work and Pensions, illness is a belief. With the right attitude (and convenient withdrawal of financial support) the temporarily ill can overcome their impairments. Just as, under neoliberalism, the unemployed, are responsible for their unemployment, so the sick are now responsible for their sickness. But this, frankly, is unscientific baloney – illness is real, whether acute or chronic.

And the idea that the UK is suffering from some kind of epidemic of psychosomatic illness just won’t wash. The amount spent by the UK on disability benefits is half what it was at its peak in the mid-90s and the benefits population is ‘static if not falling’.

In truth, what lies behind the mammoth injustice of the WCA is a refusal to accept the consequences of class. People in poorer areas die sooner and spend more of their lives contending with a disability than those in wealthier areas. In fact, the gap in disability-free life expectancy between low and high income groups is 13 years. The book, The Spirit Level, reports a study of civil servants which found that low job status was related to ‘some cancers, chronic lung disease, gastrointestinal disease, depression, suicide, sickness absence from work, back pain and self-reported health’. The authors conclude that ‘there is a sickness gradient in health running right across society … those above us have better health, those below us have worse health,  from the very bottom to the very top.’ If you want to change those outcomes, you have to change society, not tell those at the bottom, living with very real illnesses, to get their act together.

4 You might think the Work Capability Assessment is monstrously unjust but those behind it fervently believe they are fighting for social justice

I think we have to accept that, though the WCA is based on disbelieving people with actual diagnosed illnesses, Iain Duncan Smith’s tears are real. He genuinely believes he has helped the ‘disadvantaged’ by declaring the ill ‘fit for work’ and removing all financial support from the unemployed for a maximum of three years. This, as fellow partner in crime Chris Grayling once put it, is ‘tough love’. And insufferable moral worthiness is not limited to the Conservatives. Labour’s Yvette Cooper, who as DWP minister in the last Labour administration actually introduced the WCA, chided the incoming Coalition in June 2010 not to abolish the medical assessments in their zeal to cut spending across the board. To do so would be ‘deeply unfair’, she said. Yes, really.

This impenetrable sense of do-goodery stems, in my opinion, from a conviction that work is fantastically good for you. Getting more and more people into work, despite the fact that they might be seriously ill, thus becomes a matter of social justice. But when Iain Duncan Smith, or Yvette Cooper think of work, they always imagine the self-actualising, well paid kind – the kind, in fact, that they do.  But low-paid, temporary, exploitative work – the kind that people who go through the WCA are forced into – is not always good for you. In fact it can be very bad for you, as the fact that in our work-saturated society the most common reason to apply for Employment and Support Allowance is having a mental health problem, attests.

Work is not good for your health, illness is real. Apart these minor tweaks government policy towards the sick and disabled in this country makes perfect sense.

If you want to understand how politics in this country works for minorities who are never going to constitute an electorally important group, read this book. You’ll never be quite the same again.

The magic wand and biological determinism. The two faces of neoliberalism

According to Belgian psychologist Paul Verhaeghe, the psychiatric world is riven by two warring factions. On the one side there is the medical or illness model, which assumes that all mental illness stems from biological or genetic defects. Think of low serotonin levels ‘causing’ depression. Treatment involves taking pills, often indefinitely, to relieve the symptoms. Mental disorders are frequently viewed as lifelong afflictions a person must adjust to. The medical model is the dominant approach, adhered to by the majority of clinicians and doctors.

On the opposite terrain is what is known as the ‘biopsychosocial’ model. Under this way of thinking biology or genetics is relegated to a secondary position. Diagnosis focuses on the broader social context facing the individual and treatment is tailored to a person’s circumstances. This model is also far more open to a person making a recovery from mental illness.

Verhaeghe is resolutely on the minority side of the argument. “The vast majority of mental disorders are not illnesses,” he asserts, “but biopsychosocial manifestations in individuals of broader social problems.”

I believe the biopsychosocial model is essential to understanding how our capitalist, neoliberal society is at the root of many mental and physical illnesses. There is overwhelming evidence of the crucial role factors like childhood poverty, inequality, economic insecurity, loneliness, migration and bullying in increasing the risk of mental illness. According to one UK psychology professor, Richard Bentall, the link between childhood trauma and future psychiatric problems is a strong as that between smoking and lung cancer. In contrast, the medical model of mental illness just presents a closed mind.

But the biopsychosocial model also has a sinister side. It is being used to bully disabled people out of social security benefits by insisting they can make miraculous recoveries from their conditions. Disability, here, is regarded as partially caused by the attitude of the sick or disabled person. Welcome to the world-view of ‘welfare reform’ in the UK.

In defending the government’s transformation of the Disability Living Allowance into Personal Independence Payments, Conservative minister Lord Freud (the same one who believes food banks have mushroomed because they offer a free good) told the House of Lords that ‘we have gone for the biopsychosocial model’.

According to a report from the Centre for Welfare Reform, “the biopsychosocial model has been used to create new obligations for those suffering from common health problems, such as the responsibility to ‘recognise that the sick role is temporary, in the expectation of recovery’”.

In one case, the Department for Work & Pensions funded a medical trial for people with ME which was presented as an exciting success for biopsychosocial intervention. But the standard for ‘recovery’ was lowered after the research began meaning that a person’s condition could have worsened and they were still counted as having ‘recovered’.

Here is 'Biopsychosocial Man' in action: 

The DWP has incrementally re-classified the work related activity group of Employment and Support Allowance claimants (people judged unfit for work) as not really disabled. Before, the government only asserted that people in the WRAG group might be able to work at some point in the future and that full-time work could damage their health. Now, they are subject to a ‘shocking’ level of sanctions and, for new claimants, paid the same in benefits as ordinary JSA claimants, as an incentive, ministers say, to find work.

At the same time the government is trying to re-package unemployment as a personal failing or mental illness, as opposed to a social problem beyond the power of the individual to rectify. There are now psychologists in job centres and job coaches in GP surgeries.

This indicates a fatal flaw in the biopsychosocial model. When it applied to the individual alone and their ‘wrong attitudes’, it becomes coercive, tyrannical and vindictive. Applied to society at large, it is liberating.

Under neoliberalism, an unsuccessful person is either lazy or sick. If they are sick, they need pharmaceutical assistance (which creates a steady stream of profits for pharmaceutical companies). If they are lazy, their misguided attitudes need to be corrected by enlightened experts. Two sides of the same battered coin, which, sadly, is still legal tender. The social and economic organisation of society is taken as a given, and not worthy of consideration.

The medical model strikes me as a dead end, like trying to argue with someone who has their fingers lodged firmly in their ears. But the biopsychosocial model can be both oppressive and illuminating. Perhaps we need to drop the ‘psycho’. A biosocial model of illness has great explanatory power and it can’t be manipulated to scapegoat people and cloak the interests of the powerful.