Has a dependency culture made us sick?

This article by Steve Reed was first published in the British Medical Journal.

Our society operates on the basis that you make the rich work harder by paying them more, but you make the poor work harder by paying them less. Compare the multimillion pound bonuses handed out to London’s City financiers with the benefit cuts intended to encourage the poor into work.

The British government is cutting incapacity benefits because of the vast sums lost to alleged benefit cheats. Let’s put the problem in perspective. According to the charity ActionAid, more than 12 times as much money is lost through offshore corporate tax havens as through benefit fraud.1 Yet the government is planning to relax legislation aimed at reducing tax haven abuse.

Of course there are cheats in any system and they deserve to be exposed. But Britain has high numbers of people receiving incapacity benefit not because of an over-generous welfare system but because the way we treat poor people makes them ill. People who have had power taken away from them are more likely to have high levels of stress. Many poor people are denied the chance of a decent job and a decent home, yet they see all around them a voracious consumer society that has locked them out.
And the poor shall be sent empty away

Many of the coalition government’s reforms are making life harder for the very poorest people. Caps on housing benefit are moving poor families away from where there are jobs and people they know to unfamiliar areas with higher unemployment. Proposed cuts in council tax benefit will hit the working poor hardest. Job cuts in the public sector are disproportionately affecting low paid women, while working women are being clobbered with more responsibility for childcare and care for elderly relatives as public services are reined back. Cuts to local services are being targeted at the poorest parts of the country—compare the £37m (€43m; $58m) cut in funding to London’s inner city borough of Lambeth with the £1m cut in funding to its leafy and affluent Richmond borough this year. Massive cuts in the building of houses and schools and in major transport projects are throwing more people out of work at the same time as the government has scrapped schemes that get people back to work. The chancellor’s autumn statement this month froze tax credits for working families on low pay, prompting the respected children’s charity Barnardo’s to comment: “It is a desperate state of affairs when the government’s own analysis shows that a further 100 000 children will be pushed into poverty as a result of tax and benefits changes announced today.”3
Youth unemployment has topped a million for the first time in two decades, but instead of encouraging young people to upgrade their job skills the government is trebling university tuition fees and scrapping weekly payments that help children from poor families stay on in education. Telling poor people they’re lazy makes little sense when the government is making it so hard for them to find work.

The way we run public services offers more clues as to why some people are pushed into a life of dependency. How the state behaves influences how individuals behave. You can see this effect in the tax system, which the government adjusts annually to encourage behaviours it wants and discourage those it doesn’t want. A major side effect of top-down public services—especially on poorer people, who rely on more services—is that they increasingly lose their sense of self reliance. Power over key aspects of their lives is taken away as things are done to them rather than with them. The cumulative effect of being told where you will live, where your children will be educated, what happens to you when you fall ill or become older is that people lose responsibility for their own lives. They experience public services as a system that does things to them whether they want it or not. We make them dependent and then criticise them for it.

Disempowerment to the people

On some estates in Brixton, south London, seven out of 10 adults of working age have no job. Most families are single parent households usually headed by a woman. Large numbers of families are overcrowded, and, with over 500 000 people on the housing waiting list in London alone and house building close to an all time low, that is unlikely to change. Violence and antisocial behaviour is higher on these Brixton estates than elsewhere. Many children grow up without knowing any adults in full time work. They become socialised out of the idea of work. The only people they see making money in their communities are drug dealers and other criminals. When their grandparents become elderly and frail they receive care services only if their needs are severe, and then they are told who will come into their home, when they will eat, when they will bathe, and sometimes even when they will go to the toilet. The sense of disempowerment is almost total.⇓
Young people grow up with almost no idea of how they can break out of this and access the opportunities they see others in wealthier communities taking for granted. So should we be surprised when some people in these circumstances play the system if that’s the only option we’ve given them?

The problem, of course, predates the current government. Its roots go back decades. Lambeth is one of several councils across the country aiming to change the power imbalance by changing the way we run public services. As a cooperative council (www.lambeth.gov.uk/cooperativecouncil)—working in closer cooperation with the communities and people we serve—we want to give more power back to people so they can take back responsibility for their own lives. That means more cooperatively owned and managed housing, a bigger say for people using services such as home care, youth services, or schools. It will start to make a difference, but alone it is not enough. We also need to change poor people’s relationship to work so that it becomes a more positive experience.

The short route from low pay to incapacity benefit

For many low paid workers, life is becoming increasingly stressful. The Equality and Human Rights Commission’s recent review of home care for older people highlighted cases of physical abuse, theft, neglect, and disregard for privacy and dignity (November 2011).4 In April this year, the Low Pay Commission reported that 10% of home care workers are paid below the minimum wage, with some workers paid per visit rather than per hour, and with no reimbursement for travel costs.5 There’s a link between the findings of these two high profile studies. Too many home care workers, encouraged to complete each visit as quickly as possible (thus with pay as low as possible), are unable to form relationships with the older people they care for and feel pressured to complete the visit as quickly as possible. This dehumanises the service being provided and makes instances of neglect more likely. The worker has little or no job satisfaction, little incentive to do a better job, little spare cash at the end of a tough working week, and increasing levels of stress. Unsurprisingly, levels of sickness absence are high and so is employee turnover. When the stress gets too much and illness follows, some workers move on to long term sickness benefit. And it’s not just care workers. Similar examples exist in almost any low paid employment.
But there is another way. Mutual home care organisations such as Care and Share Associates (CASA) and Sunderland Home Care Associates have found they can cut both sick leave and staff turnover by giving their employees a stake in the ownership of the company they work for. More decisions are taken communally and there may be a profit sharing scheme. Even though pay rates are still relatively low, employees feel a greater sense of control over the work they do. Empowerment seems to be critical to reducing stress and increasing happiness.

Many people who have become ill and found themselves living on incapacity benefit ended up in that situation because of a toxic mixture of limited opportunity, capped aspirations, miserable working conditions, and a sense of almost total loss of power over their own lives. The stress this creates leads to illness. A dependency culture is what happens when you take power and responsibility away from people because dependency is all they’re left with.

In place of demonising the poor

We need a radical change in the power relationship between citizens and public services, and between workers and the organisations they work for. Instead of blaming unemployed people for not having a job, we need government intervention to generate more jobs and then help people develop the skills they need to do them. We must hand back power to people who have none and give them back the sense of self reliance and aspiration that politicians and councils have taken away. That approach, rather than demonising the poor, is the way to tackle dependency