# Calculus Of Libertarian Paternalism

German artist Max Ernst (1891 – 1976) incorporated a lot of sophisticated mathematical ideas into his works. Indeed, many Surrealists and Dadaists of the Anti-Tradition had a sophisticated grasp of mathematics and represented mathematics in a variety of astounding ways.

The 1942 picture, “Young Man Intrigued by the Flight of a Non-Euclidian Fly” shows a Young man observing a fly, through Euclidean triangle eyes. The fly executes a complex flight path leaving a trace behind it. That trace criss-crossing itself creates a large number of Non-Euclidian triangles. Quite literally, the Young Man is looking at a world with eyes that are utterly different to the reality of the World.

In mathematics, there are broadly three kinds of triangles: Hyperbolic, Euclidean, Elliptic. They each have three sides meeting at three corner angles and those features make them into triangles. An elliptic and hyperbolic triangle will not have corner angles adding up to one hundred and eighty degrees. Where anybody supposes that all triangles can only have angles adding up to one hundred and eighty degrees their calculations will be wrong for two types of triangles. Seeing the world through Euclidean Eyes is much the same as seeing the world through an ideological lense. Especially if the World has a different geometry. Looking at the Young Man Intrigued by the Flight of a Non-Euclidian Fly illustrates all three kinds of triangles and that gives resonance to the idea that the Young Man is intrigued. Anybody would be intrigued at the prospect that the World has hidden depths.

The assumption that all triangles are the same is wrong; but, not something that overly worries people. For enough practical situations, the Euclidean Triangle is acceptable. Good enough for Government Work. It seems obvious and has an intuitive appeal. People see triangles as having straight edges and one hundred and eighty degrees of angles. It makes sense. It is a default pattern of thought. It is what nudge theorists call choice architecture. No matter what you choose your choice will be determined by the assumption that the angles will always add up to one hundred and eighty degrees and that lines are always straight. It is the kind of inflexible thinking that Politicians of all Parties excel at: straight talking, clear thinking, up front. Sadly, the truth is the inability to address the variety in the world makes those politicians inflexible, authoritarian, and even counter-productive.

The inability to accept that, even if you do not know exactly how they work, there are Non-Euclidian triangles is something that prevents living in a world of surprises. Which is not to say that every surprise abolishes all that you know. This is a phenomenon that politicians of a certain sort use repeatedly. Mental gymnastics that present them as being flexible, dynamic, innovative where, in fact, they are inflexible, dull authoritarians. Nowhere is this more useful than in Paternalism.

Paternalism, in essence, tells the world that there is on kind of triangle. For enough practical situations, we can assume that Euclidean Triangles are the only Triangles. These situations do not include the sophisticated situation where there is rapid change and the world enters uncharted territory. Paternalism is not good at uncharted territory.

Paternalism is a political idea of limiting liberty or autonomy in a manner intended to promote the good of a person or group. That limitation of behaviour might be against or regardless of the will of a person. The Paternalist expresses an attitude of superiority: this is the correct way to do things. As a political idea, Paternalism has been unfashionable since the end of the Second World War. There is a small step from table manners to total war.

Telling people, especially people who are increasingly educated, that there is only one kind of triangle is nonsense. Paternalists classify themselves as soft or hard, pure or impure, moral or welfare; and, since the advent of nudge theory these have all been wrapped up into the notion of Libertarian Paternalism. Broadly Libertarian Paternalism is Paternalism where the subject of the Paternalism is influenced in their choices in a way that will make them better off, as judged by themselves. Libertarian Paternalism is about getting the whole world to buy into the notion that there is one, and only one, kind of triangle.

Which makes those who do not accept the nudge, metaphorically, into the wrong kind of triangle. Given there are three general kinds of geometry – Euclidean, Hyperbolic, and Elliptical – there is a two in three probability that a randomly selected triangle is the wrong kind of triangle. Which has a curiously powerful historical resonance for some people. Judging that a nudge is wrong for me places those with judgement in conflict with the Paternalist and the inevitable hardening of whatever powers the Paternalist possesses takes place. Libertarian Paternalism cannot help but become Authoritarian. Paternalism trumping Libertarianism for a very simple reason: Paternalists propose rule escalations and either the Libertarian accepts the escalation or the Paternalist escalates the coercion. There is no real free choice.

The modern paternalism has branded itself as nudge as if there was something harmless about it. In reality nudge relies on cognitive biases. There are around one hundred cognitive biases that have been identified by psychologists. These are systematic patterns of deviation from norm or rationality in judgement in other words: ways in which we assume we know what kind of triangle we are looking at. These cognitive biases result in fairly predictable outcomes. Nudge Theorists spend a lot of time designing decisions for Citizens to make around these cognitive biases which result in decisions that are not really free choices and may not even be rational. Indeed there is often a payoff for the Paternalist in having an irrational choice: the Citizen has made a choice and has no insight into why. Which ensures the Paternalist can narrate social reality simply by saying, “this is why you chose that”.

The list of cognitive biases is long and they are effective means to nudging people into taking the right decision. So, for example, the Default Effect is where, given a choice between several options, the tendency to favour the default one. This is frequently seen in computer systems where, for example, the default language is US-EN and needs to be changed. The subtle impact of this, for English Language Speakers, is that not changing the default US-EN to GB-EN, for example, results in software that is understandable but drives language use towards American semantics.

Then there is the Framing Effect: drawing different conclusions from the same information, depending on how that information is presented. So, for example, using US-EN and GB-EN rather than American English and British English helps to drive the conclusion that these are, somehow, dialects of the same language with equal linguistic value, rather than diverging languages in a struggle for existence. The list of cognitive biases is a list of ways to influence people: framing software use in US-EN has the subtle effect of making software be perceived as American, even though America is not the biggest writer of code in the world.

Cognitive biases are about getting things done: decisions made. They are not about rational decision making but about getting things done. In the word of the Philosopher Harry Frankfurt, they are about bullshit. The use of cognitive biases is not about saying something true or false but about getting things done. It is about Action. The principle of action replacing though has been central to the development of Totalitarianism for at least a century.

The danger of Paternalism is that it ceases being benevolent and becomes Total. In the practices of Nudge there is embodied a subtle yet obvious flaw: those doing the Nudging are not immune to the cognitive biases they use. They see the entire world as Euclidean Triangles – which, in a world with Elliptical and Hyperbolic triangles, amounts to confirmation bias. Confirmation Bias is the tendency to search for, interpret, focus on and remember information in a way that confirms one’s preconceptions. Being in positions of power, those who Nudge are using Confirmation Bias to inform their creation of a Framing Effect and a Default Effect. The outcome is that policies are not evidence based, rational and democratic but prejudice based, irrational and paternalistic.

When Sunstein and Thaler proposed that Libertarian Paternalism was a good idea, they were doing so from a peculiar position of having access to legal, contract and finance skills. Libertarian Paternalism would, it seem, work in a community that had replaced society with enforceable contracts.

This kind of notion seeps into the way the Department for Work and Pensions treat Claimants. The Unemployed become Job Seekers thus taking advantage of the cognitive bias of focusing; and, the Job Seeker has a Job Seekers Agreement which, it turns out, is an actual contract for which the Claimant must fulfil all conditions, however arbitrary. This is where we begin to see how Nudge is also nudging the Department for Work and Pensions.

Job Seekers are viewed as being lumps of labour that can be switched in and out of the Economy mechanistically. This amounts to the cognitive bias of functional fixedness. Which separates the Claimant from any access to legal, contractual or finance resources implicit in the Sunstein and Thaler presentation of Nudge Theory. Which reduces the interaction between the Department and the Claimant to a Paternalistic relationship. Indeed, the nature of that relationship is reinforced by the elimination of legal aid: there is no recourse to effective contract drafting for the Claimant and the whole relationship is determined by who has the deepest pockets.

The Department of Work and Pensions is the clearest example of how Nudge becomes Authoritarianism. The elements that make Nudge workable have all been eliminated. There is no possibility of each Claimant negotiating a realistic Job Seekers Agreement and so the agreement will be dictated, to save time if nothing else. This highlights one of the cognitive biases of the Department: illicit transference – the notion that what is true of one claimant is true of all Claimants or what is true of Claimants collectively is also true of Claimants individually.

Because the Department of Work and Pensions has abandoned the evidence based work in favour of Observer-expectancy “Randomised Control Trials” – there is a veneer of scientific respectability. Yet, the Randomised Control Trials do not actually stand up to scrutiny. Which is evidenced by the consequent Departmental use of statistics. The Department of Work and Pensions has a poor reputation for statistics – being disciplined by the National Audit Office on several occasions – which highlights the Department’s predilection for cognitive biases such as Zero risk bias, Unit Bias, Stereotyping, and Status Quo Bias.

The clear outcome is that, once the capacity for all parties to a nudge to act in a libertarian fashion is removed, all that is left is Paternalism. It is a choice. A choice made in a choice architecture: the choice is transferred from the Claimant or the Citizen to the Department or the Government. Nudge is little more than the choice architecture of authoritarianism. This is no more evident than in the choice of Austerity.

The outcome of Austerity has been the rise of social murder – the killing of reasonably well defined groups such as Claimants – often at considerable cost, in order to sustain a cognitive bias. The multiple cognitive biases, of the Tories, used to support the claim that Markets solve everything are little more than the denial that there is more than one kind of triangle. Independent observers – such as UN Special Rapporteur Philip Alston – have pointed out that Austerity is a choice that could be reversed ‘overnight’ for little cost. It is a choice. Made within a choice architecture created by Authoritarians.

The social murder carried out since 2010 is in the process of transforming society. Obedience is being presented as the default choice. In reality, the cognitive bias of System Justification, is driving the political, economic and social destruction of society and social murder is an acceptable outcome because “society will be reformed”.

It is the same notion that instruction to action – of taking back control – of keeping calm and carrying on – all signify. It is about remaking society in the image of some historical bubble: the cognitive biases of False Memory about some golden age, possibly in the 1940s or 1950s, where the world was somehow, magically, better. It was a world in which there was only one kind of triangle. It was also a world in which Max Ernst was fleeing totalitarians who wanted to kill him for painting the wrong kind of triangle.

Picture: “Young Man Intrigued by the Flight of a Non-Euclidean Fly”, Max Ernst, 1942.

Article by Hubert Huzzah

# The Choice Architecture Of Poverty

Special Rapporteur Philip Alston has presented a United Nations Report on Poverty in the UK. The UK Mainstream Media have not really excelled in analysis or presentation of the findings. After almost a decade of Nudge by Press Release, the Guardian has missed the vital message while the BBC has simply recycled old Government Press Releases. The Mainstream Media seem to be shy about embracing the most damning finding of the report.

In December 2017, Professor Alston carried out a visit to the USA – California, Alabama, Georgia, Puerto Rico, West Virginia, and Washington DC – carrying out the same kind of investigation as has just finished in the UK. The most damning finding of the UN-US Report on Poverty was similar to the most damning finding of the UN-UK Report on Poverty. Had the Guardian excelled in Journalism they might have highlighted that the UN was not simply finding something isolated.

The Guardian and the BBC might not have concluded that the “Government is in denial” because following the implications of the most damning finding is that POVERTY IS A CHOICE

Both in 2017, in the USA, and in 2018 in the UK, the UN has concluded that poverty is a choice and that Government has made the decision that the only choice on offer is compliance or poverty. The Mainstream Media is failing to follow any kind of analysis that follows the implications of the finding that poverty is a choice and there is no adequate explanation as to why? The notion that poverty is a choice is one that has been foisted onto everybody by the Government since 2010. Welfare Changes have been touted as Reforms which will enable people to choose to lift themselves out of poverty. That choice takes place within the Choice Architecture that has been created by policy.

In the UN-US Report, Alston states that:

“ …I heard how thousands of poor people get minor infraction notices which seem to be intentionally designed to quickly explode into unpayable debt, incarceration, and the replenishment of municipal coffers…”

In the UN-UK Report, Alston similarly finds that:

One of the key features of Universal Credit involves the imposition of draconian sanctions, even for infringements that seem minor. Endless anecdotal evidence was presented to the Special Rapporteur to illustrate the harsh and arbitrary nature of some of the sanctions, as well as the devastating effects that resulted from being completely shut out of the benefits system for weeks or months at a time. As the system grows older, some penalties will soon be measured in years.”

The Mainstream Media make no connection between the American Experience and the British Experience. As if there was no connection between US Policy and UK Policy. As if all the shuttling back and forth between Republicans and Conservatives has never had any impact. As if the Minor Infraction Notices are, in no way, related to Benefit Sanctions. There is an almost willing blindness: never stray from the press release.

The UN Rapporteur was never commissioned to analyse Nudge Theory. The outcome of eight years of Libertarian Paternalism has transformed British Society into something that, the UN recognises, punishes the Poverty it also chooses to deliver. The overwhelming Mainstream Media response has been the Punch and Judy caricature and Poverty Porn Prurience instead of analysis.

How did a Government get to the point where Human Rights are optional or contingent upon being an Employee: this is a question central to the current Welfare Policy which is transforming British Society. It also has an answer that the UN Rapporteur gives: POVERTY IS A CHOICE.

In putting forward an endless series of press releases and promoting the production of daytime television portraying skivers and strivers the Department of Work and Pensions has been nudging the Mainstream Media into only presenting a narrative where strivers can choose to leave poverty and only skivers would want to avoid that choice. The constant nudging – the well written Press Releases that, frequently, substitute for actual Journalism – has worked. The Government has decided to provide the choice of poverty in a range of ways.

The Government provision of choices of poverty underline that decisions are placed beyond Claimants in a calculated and cruel manner. The Choice Architecture prevents Claimants from making decisions. Decisions would empower Claimants and also permit innovation. Claimants could determine what is the best course of action. Instead the digital by default process has been used to provide a series of choices without any deviation permitted.

A Claimant who fails to fill in any choice – and fill it in correctly, and fill it in digitally – automatically chooses poverty. Similarly, those who fail to know that choices have been proffered are choosing poverty. The complexity of the choice architecture is overwhelming – even for those engaged in administering it. It is a system that has been designed to deliver poverty – and it has.

The skills to interact with a State that is being made actively oppositional and digital as the UN-UK Report highlights:

The reality is that digital assistance has been outsourced to public libraries and civil society organizations. Public libraries are on the frontline of helping the digitally excluded and digitally illiterate who wish to claim their right to Universal Credit.”

Which is not too distant from the UN-US Report:

Much more attention needs to be given to the ways in which new technology impacts the human rights of the poorest Americans. This inquiry is of relevance to a much wider group since experience shows that the poor are often a testing ground for practices and policies that may then be applied to others. These are some relevant concerns.”

The truth is, the US and the UK have parallel tracks in overarching Policy objectives: eliminate the State and have the Poor fend for themselves. The emphasis on digital systems as a means to distance Policy Makers from Policy Delivery and to “cut costs” is evident across the US and UK Reports. Pretrial detention has been an area calling for systematic reform in the US for decades. The UN-US Report observes:

Automated risk assessment tools, take “data about the accused, feed it into a computerized algorithm, and generate a prediction of the statistical probability the person will commit some future misconduct, particularly a new crime or missed court appearance.”

The system will generally indicate whether the risk for the particular defendant, compared to observed outcomes among a population of individuals who share certain characteristics, is ‘high’, ‘moderate’, or ‘low’. Judges maintain discretion, in theory, to ignore the risk score.”

Which reflects the “automated” nature of the Work Capability Assessment for the Disabled in the UK, previously reported by the UN as being either at risk or actually in the process of grave human rights abuse. In the UN-UK Report the Automated Risk Assessment tools are commented upon:

But it is clear that more public knowledge about the development and operation of automated systems is necessary. The segmentation of claimants into low, medium and high risk in the benefit system is already happening in contexts such as ‘Risk-based verification.’ Those flagged as ‘higher risk’ are the subject of more intense scrutiny and investigation, often without even being aware of this fact. The presumption of innocence is turned on its head when everyone applying for a benefit is screened for potential wrongdoing in a system of total surveillance. And in the absence of transparency about the existence and workings of automated systems, the rights to contest an adverse decision, and to seek a meaningful remedy, are illusory.”

Which underlines that the Government of the day – regardless of political inclination – are delivering Policy Objectives without transparency, clarity or even sufficient information to determine what the Policy Objectives are. When policy objectives only become clear through outcomes, there is a clear suspicion that Democracy has been subverted. Which is the general direction the UN-US and UN-UK Reports indicate. There are serious Human Rights failings but also a serious democratic deficit arising from the idea that POVERTY IS A CHOICE.

The use of Computer Systems is not neutral or innocent. The Special Rapporteur notes that:

it is worrying that the Data Protection Act 2018 creates a quite significant loophole to the GDPR for government data use and sharing in the context of the Framework for Data Processing by Government.”

Which is not simplistically that UK Government Departments have “rights” to trawl through personal data but that it is increasingly criminalised for Claimants – more than eight million people – to object to that trawl or to object to the sharing of data with Commercial Contractors. Those same Contractors being Employers and the inevitable consequence of data sharing being to put Claimants at a distinct power and negotation disadvantage when contracts of Employment are considered. Because the UK Government Departments have zero obligation to ensure Claimants get the best possible job. Simply that Claimants flow off the Register.

Which is how POVERTY IS A CHOICE is being delivered from Government to the People. Interaction with the Department of Work and Pensions has become the single most corrosive interaction with Government that People can have. The design of benefits has become an exercise in delivering the ideological convictions of the Government regardless of the practicality of those convictions. For the Conservative Government, that conviction is that people should be in poverty unless they are Employed. Which ensures the disabled, parents, students, pensioners, entrepreneurs in start-up and Carers are locked into a combative process in which the only exit is to choose poverty.

The UK Mainstream Media is not really exploring this dimension of the UN Rapporteur’s commentary. It leads to uncomfortable terrain for any Journalist. Not least, the intimate connection between the Republicans in the US and the Conservatives in the UK. The ideological convergence of the Conservatives with the Republicans has delivered a wide range of public policy disasters. The Department of Work and Pensions has been allowed carte blanche to redesign the Welfare State based on the Workfare preferred by the Republicans.

The Nudge Unit has crossed, and recrossed, the Atlantic ensuring that the Conservative’s historic prejudice for “the right to manage” has become inflated. Including all aspects of social existence into contractual relationships between the Government and the People. Dating back to Ronald Reagan’s 1985 “Contract with America” speech where everything was reduced to legislation as contract and society became replaceable with a well ordered business.

The UK Mainstream Media is not really capable of exploring these ideas because, quite simply, to do so is to undermine the interests of their owners. Without any need for coercion, the Government is capable of nudging the Media into endlessly propagating the POVERTY IS A CHOICE agenda.

Despite the comprehensive nature of the UN Rapporteurs investigations and reporting, there is little about the UN-UK Report that is actually surprising. The connection between the UN-UK and UN-US Reports might well be a surprise to the Media. Realistically, there should be no surprise at all. The Extremists of The Atlantic Bridge, The Heritage Foundation and all the myriad of Far Right Think Tanks since Reagan, have all been promoting the same ideas both sides of the Atlantic. They have all been ensuring that the tools exist for Government to make only once choice possible for the People and that choice is Poverty.

Picture: Mika Rottenberg, Bowls Balls Souls Holes, Video Installation Rose Art Museum Waltham USA (2104).

# ‘Pointlessly cruel’ sanctions regime must be reassessed, says Commons Select Committee

The Work and Pensions Committee has published a report this month regarding the findings of an ongoing inquiry into welfare conditionality and sanctions.

The Committee says in the report:“Of all the evidence we received, none was more compelling than that against the imposition of conditionality and sanctions on people with a disability or health condition. It does not work.

“Worse, it is harmful and counterproductive. We recommend that the Government immediately stop imposing conditionality and sanctions on anyone found to have limited capability for work, or who presents a valid doctor’s note (Fit Note) stating that they are unable to work, including those who present such a note while waiting for a Work Capability Assessment. Instead, it should work with experts to develop a programme of voluntary employment support.”

The report concludes that “The human cost of continuing to apply the existing regime of benefit sanctions – the ‘only major welfare reform this decade to have never been evaluated’ – appears simply too high. The evidence that it is achieving its aims is at best mixed, and at worst showing a policy that appears ‘arbitrarily punitive’.”

The Committee says the Coalition Government “had little or no understanding of the likely impact of a tougher sanctions regime” when it introduced it in 2012 with the stated aim, as the NAO describes it, that “benefits, employment support and conditions and sanctions together lead to employment.”

At that point, the Government promised to review the reform’s impact and whether it was achieving its aims on an ongoing basis. But six years later, Government “is none the wiser.”

As one expert witness suggested, “if it was not for the embarrassment, the Government would have suspended Employment and Support Allowance (ESA) sanctions altogether as soon as that National Audit Office finding came out that sanctioned ESA claimants were less likely to get into work.”

#### Some groups ‘disproportionately vulnerable’

The report highlights that single parents, care leavers and people with a disability or health condition are disproportionately vulnerable to and affected by the withdrawal of their benefit. The Committee says that “until the government can show unequivocally that sanctions actually help to move these claimants into work, it cannot ‘justify these groups’ continued inclusion in the sanctions regime’.

In the meantime, and until that positive link is proven, people who are the responsible carer for a child under the age of 5, or a child with demonstrable additional needs and care costs, and care leavers under the age of 25, should only ever have a maximum of 20% of their benefit withheld.”

The report authors go on to say: “The Department for Work and Pensions (DWP) must urgently evaluate the effectiveness of the reforms to welfare conditionality and sanctions since 2012, including their impact on people’s financial and personal well-being.

“Until the Government can point to ‘robust evidence that longer sanctions are more effective’, higher level sanctions should be reduced to 2, 4 and 6 months for first, second and subsequent failures to comply”.

The report goes on to say: “Government should also “immediately stop imposing conditionality and sanctions on anyone found to have limited capability for work, or who presents a valid doctor’s note” stating they cannot work. Instead, it should work with experts to develop a programme of voluntary employment support for those who can get into work.”

#### Sanctions have no effect on in-work claimants

Randomised Controlled Trials have shown sanctions had no effect on in-work claimants’ outcomes, and work coaches are not yet equipped to get enough decisions right. Sanctioning people who are working is too great a risk for too little return. DWP should not proceed with conditionality and sanctions for in-work claimants until full roll-out of Universal Credit is complete, and even then, only introduce sanctions on the basis of robust evidence that it will be effective at driving progress in work.

Comment from Work and Pensions Committee Chair Frank Field MP

“We have heard stories of terrible and unnecessary hardship from people who’ve been sanctioned. They were left bewildered and driven to despair at becoming, often with their children, the victims of a sanctions regime that is at times so counter-productive it just seems pointlessly cruel.

While none of them told us that there should be no benefit sanctions at all, it can only be right for the Government to take a long hard look at what is going on. If their stories were rare it would be unacceptable, but the Government has no idea how many more people out there are suffering in similar circumstances. In fact, it has kept itself in the dark about any of the impacts of the major reforms to sanctions introduced since 2012.

The time is long overdue for the Government to assess the evidence and then have the courage of its reform convictions to say, where it is right to do so, ’this policy is not achieving its aims, it is not working, and the cost is too high: We will change it.”

The Work and Pensions Committee are currently looking into the Government’s plans for moving people who are already claiming benefits onto Universal Credit, which merges six “legacy” benefits into one, single, monthly household payment. The Government calls this “managed migration”. The Committee is also looking at the impact of the changes announced by the Government in the 2018 Budget.

Most recent evidence session: PDF version (268 KB) | Published 27 Oct 2018.

Evidence given by Steven McIntosh, Director of UK Poverty Policy, Advocacy and Campaigns, Save the Children, Dalia Ben-Galim, Director of Policy, Gingerbread, Joe Shalam, Researcher, Centre for Social Justice, Jonathan Broadbery, Head of Policy and External Relations, National Day Nurseries Association Gaynor Rowles, Hairdresser, Lucy Collins, Beauty technician, Vikki Waterman, Administrator, Thuto Mali, full time mum.

Watch this evidence session.

Related

New research shows welfare sanctions are punitive, create perverse incentives and are potentially life-threatening

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# GPs told to consider making fit notes conditional on patients having appointment with work coach

Thanks to for the copy of a patient work coach letter to GPs.

One of the most worrying comments on the above letter is that despite claiming the work coach service is voluntary, and that if a patient refuses to engage “it won’t affect any benefit they get”, the letter then goes on to suggest that doctors may consider the issuing of subsequent fit notes conditional (“with the proviso that”) on their patient attending a meeting with the work coach. That one sentence simply makes a mockery of the claim that patient engagement with work coaches is voluntary.

Illnesses don’t respond to provisos or caveats. People don’t suddenly recover when the Department for Work and Pensions decides that they are fit for work. When job centre staff tell GPs to stop issuing sick notes to patients it can have catastrophic consequences, from which the government never seem to learn. In fact they don’t even acknowledge the terrible costs that their deeply flawed policies are inflicting on citizens.

Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. In 2016, she wrote a letter (an ESA65B notification form) addressed to a GP regarding a seriously ill patient. It said:

We have decided your patient is capable of work from and including January 10, 2016.

“This means you do not have to give your patient more medical certificates for employment and support allowance purposes unless they appeal against this decision.

“You may need to again if their condition worsens significantly, or they have a new medical condition.”

The GP subsequently repeatedly refused to provide him with new fit notes, even as his health deteriorated, and he died months later.

James Harrison – the patient – had been declared “fit for work” and the letter stated that he should not get further medical certificates. The Department for Work and Pensions contacted his doctor without telling him, and ordered him to cease providing sick certification, James died, aged 55.

He was very clearly not fit for work.

I is very worrying that the ESA65B form is a standardised response to GPs from the Department for Work and Pensions following an assessment where someone has been found fit for work.

#### The government as boardroom doctors: political jobsworths

The Department for Work and Pensions issued a new guidance to GPs in 2013, regarding when they should issue a Fit Note. This was in December 2016.

In the dogma document, doctors are warned of the dangers of “worklessness” and told they must consider “the vital role that work can play in your patient’s health”. According to the department, “the evidence is clear that patients benefit from being in some kind of regular work”

As a matter of fact, it isn’t clear at all.

The idea that people remain ill deliberately to avoid returning to work  – what Iain Duncan Smith and David Cameron termed “the sickness benefit culture” – is not only absurd, it’s very offensive. This is a government that not only disregards the professional judgements of doctors, it also disregards the judgements of sick and disabled people. However, we have learned over the last decade that political “management” of people’s medical conditions does not make people healthier or suddenly able to work.

Government policies, designed to ‘change behaviours’ of sick and disabled people have resulted in harmdistress and sometimes, in premature deaths.

Call me contrary, but whenever I am ill with my medical and not political illness, I generally trust my qualified GP or consultant to support me. I would never think of making an appointment to see the irrational likes of Esther McVey or Iain Duncan Smith for advice on lupus, or to address my health needs and treatment.

The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the ghastly implications of permitting job coaches to update patient medical files), the merging of health and employment services and the recent absurd declaration that work is a clinical “health” outcome, are all carefully calculated strategies that serve as an ideological prop and add to the justification rhetoric regarding the intentional political process of dismantling publicly funded state provision, and the subsequent stealthy privatisation of Social Security and the National Health Service.

De-medicalising illness is also a part of that increasingly behaviourist-neoliberal process:  “Behavioural approaches try to extinguish observed illness behaviour by withdrawal of negative reinforcements such as medication, sympathetic attention, rest, and release from duties, and to encourage healthy behaviour by positive reinforcement: ‘operant-conditioning’ using strong feedback on progress.” Gordon Waddell and Kim Burton in Concepts of rehabilitation for the management of common health problems. The Corporate Medical Group, Department for Work and Pensions, UK.

Waddell and Burton are cited frequently by the Department for Work and Pensions (DWP) as providing ‘scientific evidence’ that their policies are “verified” and “evidence based.” Yet the DWP have selectively funded their research, which unfortunately frames and constrains the theoretical starting point, research processes and the outcomes with a heavy ideological bias.

This behaviourist framing simply shifts the focus from the medical conditions that cause illness and disability to the ‘incentives’, behaviours and perceptions of patients and ultimately, to neoliberal notions of personal responsibility and self-sufficient citizenship in the dehumanising context of a night watchman, non-welfare state, absent of any notion of human rights.

Medication, rest, release from duties, sympathetic understanding – the remedies to illness – are being appallingly redefined as ‘perverse incentives’ for ill health, yet the symptoms necessarily precede the prescription of medication, the Orwellian renamed (and political rather than medical) “fit note” and exemption from work duties. Notions of ‘rehabilitation’ and medicine are being redefined as behaviour modification: here it is proposed that operant conditioning in the form of negative reinforcement –  punishment – will cure’ ill health.

It’s a completely slapstick rationale, hammered into shape by a blunt instrument – political ideology. People cannot simply be ‘incentivised’ (coercion is a more appropriate term) into not being ill. Punishing people for being poor by removing their support does not ‘help’ them to stop being poor, either, despite the  doublespeak and mental gymnastic pseudoscientific rubbish the government spouts.

#### Turning health care into a government work programme

The government dogmatically assert “The idea behind the fit note is that individuals do not always need to be fully recovered to go back to work, and in fact it can often help recovery to return to work.”

It was 2015 when I wrote a breaking article about the government’s Work and Health programme, raising concerns that the Nudge Unit team were working with the Department for Work and Pensions and the Department of Health to trial social experiments aimed at finding ways of: “preventing people from falling out of the jobs market and going onto Employment and Support Allowance (ESA).”

“These include GPs prescribing a work coach, and a health and work passport to collate employment and health information. These emerged from research with people on ESA, and are now being tested with local teams of Jobcentres, GPs and employers.”

Of course the government hadn’t announced these ‘interventions’ in the lives of ill and disabled people. I found out about it quite by chance because I happened to read Matthew Hancock’s  conference speech: The Future of Public Services.

I researched a little further and found an article in Pulse – a publication for for medical professionals – which confirmed Hancock’s comment: GP practices to provide advice on job seeking in new pilot schemeI posted my own article on the Pulse site in October 2015, raising some of my concerns.

Many of us have warned that the programme jeopardises doctor-patient confidentiality, risks alienating patients from their doctors and perverts the primary role and ethical mission of the healthcare system, which is to help people to recover from illnesses. Placing job coaches in GP surgeries makes them much less inaccessible, because it turns tappointments potentially into areas of pressure and coercion. That is the very last thing someone needs when they become ill.

One worry was that the government may use the ‘intervention’ as a further opportunity for sanctioning ill and disabled people for ‘non-compliance’. People who are ill often can’t undertake work related tasks precisely because they are ill. Until recent years, this was accepted as common sense, and any expectation of sick people having to conform with such rigid welfare conditionality was quite properly regarded as both unfair and unrealistic.

I expressed concern that the introduction of  job coaches in health care settings, peddling the myth that ‘work is a health outcome’ would potentially conflict with the ethics and role of a doctor. I also stated my concern about the potential that this (then) pilot had for damaging the trust between doctors and their patients.

In another article in 2016, titled Let’s keep the job centre out of GP surgeries and the DWP out of our confidential medical records, I outlined how GPs had raised their own concerns about sharing patient data with the Department for Work and Pensions – and quite properly so.

Pulse reported that the Department for Work and Pensions (DWP) plans to extract information from GP records, including the number of Med3s or so-called ‘fit notes’  issued by each practice and the number of patients recorded as ‘unfit’ or ‘maybe fit’ for work, in an intrusive move described by GP leaders as amounting to “state snooping.”

Part of the reason for this renewed government attack on ill and disabled people is that the Government’s flagship fit note scheme, which replaced sick notes five years ago in the hope it would see GPs sending thousands more employees back to work to reduce sickness-related absence, despite GPs having expressed doubts since before its launch, has predicably failed.

The key reason for the failure is that employers did not take responsibility for working with employees and GPs seriously, and more than half (59%) of employers said they felt unable to support employees by making all of the legally required workplace adjustments for those who had fit notes signed as “may be fit for work.” Rather than address this issue with employers, the government has decided instead to simply coerce patients back into work without essential support.

Another reason for the failure of this scheme is that most people who need time off from work are ill and genuinely cannot return to work until they have recovered. Regardless of the government’s concern for the business and state costs of sick leave, people cannot be simply ushered out of illness and into work by the state to “contribute to the economy.”

When a GP says a person is ‘unfit for work’, they generally ARE unfit for work, regardless of whether the ‘business friendly’ government likes that or not. And regardless of the politically prescribed Orwellian renaming of sick notes, which show ‘paternalist’ linguistic behaviourism in action.

In 2017, the General Medical Council (GMC) – independent regulator for doctors in the UK – wrote a response to the government’s green paper: Improving Lives: The Work, Health and Disability Green Paper consultation. The authors of the document begin by saying ” Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.”

The response continues: “Where doctors are expected to play a role in initiatives such as those set out in the Green paper, our concern is to ensure that any responsibilities that might be placed on doctors would be consistent with their professional obligations and would not risk damaging patients’ trust in their doctors. While we believe that many of the Green paper proposals are promising, we are concerned that key elements appear to present a conflict with the ethical responsibilities we place on doctors. The comments below are seeking clarification in these areas.”

And: “We understand from this Green paper, and from the Department of Work and Pensions’ published FOI response, dated 22 December 2016, that the work coaches who will conduct the mandatory health and work conversation with claimants will not be health professionals. There is a risk that claimants will not get the right support in setting health and work-related goals during this mandatory conversation if the work coach does not have clinical expertise.

“It would be helpful to know whether work coaches will be expected to have access to the claimant’s healthcare team and/or health records to inform these conversations. If so, we would appreciate reassurance that there will be a process for obtaining consent from the claimant, and providing assurance to the relevant health professionals that the individual has provided consent. Given that work coaches do not require medical expertise, we have some concerns about these conversations leading claimants to agree to health-related actions in a Health and Work ‘claimant commitment’. It seems possible that agreed actions might not be clinically appropriate for that individual or not the best course of action given their health condition.

If a claimant commitment were reviewed by the claimant’s doctor (or other healthcare professional), and the doctor concluded that there was a health risk; then would the claimant be free to withdraw from the commitment without facing a benefits penalty? If not, then this would put the doctor and patient in a very difficult position, if it appeared that the patient had been poorly advised by the work coach and was not making an informed, voluntary decision in requesting a particular treatment or care regime from their doctor.

We note the intention is for any agreement made in the Health and Work Conversation to be seen as voluntary. However, it seems to us that since the Conversation itself is mandatory and a Claimant commitment may influence subsequent handling of an individual’s Work Capability assessment, then in practice claimants may see these agreements as mandatory.

“As a result they may feel pressured to accept advice and make commitments which may not be appropriate in their case. This would place theirdoctors in a difficult ethical position, and we are concerned to ensure that this is not the case.

The authors add: “… we make it clear in our guidance that doctors must consider the validity of a patient’s consent to treatment if it is linked with access to benefits. Doctors should be aware that patients may be put under pressure by employers, insurers, or others to accept a particular investigation or treatment (paragraph 41, Consent: patients and doctors making decisions together).

“Difficulty could arise if a doctor does not believe that a patient is freely consenting to treatment and is instead only giving consent due to financial pressure. Doctors must be satisfied that they have valid consent before providing  treatment, which means they could be left with a difficult decision as to whether to refuse treatment in the knowledge that this could affect the patients benefit entitlements.”

The GMC also raise concerns about how sensitive health data is collected and shared for purposes other for patients’ direct care, without patients being informed or giving consent. The government have simply proposed to access health care data to support “any assessment for financial support” and told GPs to assume consent has been given.

#### Promoting the myth that work is a ‘clinical outcome’

A Department for Work and Pensions research document published back in 2011 – Routes onto Employment and Support Allowance – said that if people believed that work was good for them, they were less likely to claim or stay on disability benefits.

Of course it may be the case that people in better health work because they can, and have less need for healthcare services simply because they are relatively well, rather than because they work.

From the document“The belief that work improves health also positively influenced work entry rates; as such, encouraging people in this belief may also play a role in promoting return to work.”

The aim of the research was to “examine the characteristics of ESA claimants and to explore their employment trajectories over a period of approximately 18 months in order to provide information about the flow of claimants onto and off ESA.”

A political decision was made that people should be “encouraged” to believe that work was “good” for their health. There is no empirical basis for the belief, and the purpose of encouraging it is simply to cut the numbers of disabled people claiming Employment and Support Allowance (ESA) by “helping” them into work.

Another government document from 2014 – Psychological Wellbeing and Work – says: We know that being in work is good for wellbeing and that mental health problems are an increasing issue for the nation and so the Minister for Welfare Reform and the Minister for Care and Support jointly sought to expand the evidence base on common mental health problems.

“A number of Government programmes assess and support those with mental health difficulties to work, but it is internationally recognised that the evidence base for successful interventions is limited.

“The Contestable Policy Fund gives ministers alternative avenues to explore new thinking and strategies that offer cross-Government benefits. This report was commissioned through this route.”

And: “Within the time and resources available for this study the research team did not undertake extensive assessment of the quality of the evidence base (eg assessing the research design and methodology of previous studies)”

The government have gone on to declare with authoritarian flourish that they now want to reinforce their proposal that “work is a health outcome.” Last year, a report by the Mental Health Task Force and chaired by Mind’s Paul Farmer, recommended that employment should be recognised as a ‘health outcome’.  I’m just wondering how people with, say, personality disorders, or psychosis are suddenly going to overcome the nature of their condition and all of a sudden successfully hold down a job for a minimum of six months.

Mind those large logical gaps…

This has raised immediate concerns regarding the extent to which people will be pushed into work they are not able or ready to do, or into bad quality, low paid and inappropriate work that is harmful to them, under the misguided notion that any work will be good for them in the long run.

It has become very evident over recent years that the labour market is not delivering an adequate income for many citizens and despite “record levels of employment”, the problem seems to be getting bigger. The government’s answer to the problem has been to extend  rather than tackle employers who pay exploitative, low wages.

The idea of the state persuading doctors and other professionals to “sing from the same [political] hymn sheet”, by promoting work outcomes in social and health care settings is more than a little Orwellian. Co-opting professionals to police the welfare system is very dangerous.

In linking receipt of welfare with health services and “state therapy,” with the single intended outcome explicitly expressed as employment, the government is purposefully conflating citizen’s widely varied needs with economic outcomes and diktats, isolating people from traditionally non-partisan networks of relatively unconditional support, such as the health service, social services, community services and mental health services.

Public services “speaking with one voice” as the government are urging, will invariably make accessing support conditional, and further isolate already marginalised social groups. Citizens’ safe spaces for genuine and objective support is shrinking as the state encroaches with strategies to micromanage those using public services. This encroachment will damage trust between people needing support and professionals who are meant to deliver essential public services, rather than simply extending government dogma, prejudices and discrimination.

State micromanagement of tenants

The GMC say in their response to the government’s proposals: “We are unclear about the evidence that might support a move to the position that ‘being in employment’ should be regarded as a ‘clinical outcome’ that healthcare professionals are expected to work towards with people of employment age seeking health-related advice and treatment. This is a highly contentious issue and indeed Dame Carol Black’s report certainly makes clear that there is limited support for this within the profession.”

I’m not unclear. There is no evidence. In an era of small state neoliberalism and ideologically driven austerity, it is an act of sheer political expediency to claim that ‘worklessness’ is the reason for the poor health outcomes that are in fact correlated with increasing inequality, poverty and lower standards of living – higher mortality;  poorer general health, long-standing illness, limiting longstanding illness; poorer mental health, psychological distress, psychological/psychiatric morbidity; higher medical consultation, medication consumption and hospital admission rates.

Both social security and the National Health Service have been intentionally underfunded and run down by the Conservatives, who have planned and partially implemented a piecemeal privatisation process by stealth, to avoid a public backlash.

Unemployment (not ‘worklessness’ –  that’s part of the privileged discourse of neoliberalism, which serves to marginalise the structural aspects of persistent unemployment and poverty, by transforming these into individual pathologies of benefit ‘dependency ‘and ‘worklessness’) is undoubtedly associated with poverty, because welfare provision no longer meets the most basic living costs.

However to make an inferential leap and claim that work is therefore ‘good’ for health’ is incoherent, irrational and part of an elaborate political gaslighting campaign of an authoritarian government, who simply don’t want to address growing poverty and inequality caused by their own neoliberal policies.

The direction that government policy continues to be pushed in represents a serious threat to the health, welfare, wellbeing, basic human rights, democratic inclusionand lives of patients and the political independence of health professionals.

Related

The new Work and Health Programme: government plan social experiments to “nudge” sick and disabled people into work

Illustration by Jack Hudson

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# Cash for Care: nudging doctors to ration healthcare provision

Today, while everyone is being distracted by the continuing resignations from Theresa May’s disintegrating government, the Conservatives are openly talking among themselves (again) about charging for NHS services. So much for the government’s continued reassurances and promises about UK healthcare continuing to remain ‘free at the point of access.’

The NHS has never been safe in  Conservatives hands.

Last week I wrote an article about the stealthy creep of rationing of treatments in the NHS, and how gatekeeping has become a watchword within our public services over the past seven years. It’s being driven by the government’s deep affection for neoliberal dogma, the drive for never-ending ‘efficiency savings’ and the Conservatives’ lean, mean austerity machine. Perish the thought that the public may actually need to use the public services that they have funded through their contributions to the Treasury, in good faith.

One important point I didn’t raise in the article was about how the marketisation of the NHS has given rise to ‘perverse incentives’, which violate the very principles on which the national health service was founded. Neoliberal policies have shifted priorities to developing profitable ‘care markets’ making ‘efficiency’ savings and containing costs, rather than delivering universal health care.

Another shift in emphasis is the “behavioural turn”. It’s politically convenient to claim that people’s behaviours are a major determinant of their health. Some illnesses are undoubtedly related to lifestyle – type two diabetes, for example. But it is difficult to blame individual’s behaviours for type one diabetes, which is an autoimmune disease, and these may happen to people who lead very healthy lifestyles, as well as those who don’t. This ‘behavioural turn’ shifts emphasis from the impact of structural conditions – such as rising inequality and poverty – on public health. It also provides a political justification narrative for cuts to healthcare and welfare provision. (See also

Behavioural economists have claimed that ‘nudge’ presents an effective way to ‘change behaviours’ within the NHS and ‘improve outcomes’ at lower cost than traditional policy tools. Back in 2015, the Nudge Unit were looking for “many potentially fruitful areas in which to use behavioural insight to improve health and health-service
efficiency, either by retrofitting existing processes or by designing completely new services most effectively.” ‘Fruitful’ as in lucrative for the part-privatised company, but not so lucrative for the NHS.

Behavioural economists are working for the government and public sector to “harness [public] behaviours to shift and reduce patterns of demand in many public services.” The problem is that human needs arising from illness are not quite the same thing as human behaviours and roles, yet the government are increasingly conflating the two. (See discussion on Talcott Parsons and the ‘sick role’ in this article, for example, along with that on ‘work is a health outcome’.)

Public services are associated with fundamental human rights, which in turn are based on notions of fundamental human need. Addressing basic human needs is fundamental to survival.

As Abraham Maslow concluded, motivation for behaviours is is closely related to fulfiling our basic needs, because if they are not met, then people will simply strive to make up the deficit as a priority. This undermines aspiration and human potential. Fulfilment of psychosocial needs will become a motive for behaviour only as long as basic physiological needs ‘below’ it have been satisfied. Health is a fundamental human need. To paraphrase Maslow, we don’t live by bread alone, unless there is no bread.

Public services are an essential part of developed democracies, they ensure all citizens can meet their basic needs, and therefore, the provision promotes wider social and economic wellbeing and progress.

Maslow’s hierarchy of human needs

The Nudge Unit had already run a trial in Nottingham, which provided feedback to doctors of the cost of a commonly used discretionary lab test. This prompt retained clinical freedom, and did not ask doctors to order fewer tests – but the number of
tests fell by a third.

In 2016 the UK government set a target to half ‘inappropriate’ antibiotic prescribing by 2020. The Nudge Unit set out to “improve prescribing in line with government ambitions”.

Behavioural economists from the Unit claimed that by informing doctors that they are prescribing more antibiotics relative to 80 per cent of their peers, they are reducing the number of ‘unnecessary’ prescriptions by 3.3 per cent (more than 73,000 prescriptions) – helping to address what the Chief Medical Officer has identified as perhaps the greatest medical threat of our age – antibiotic resistance.

Between 2014 and 2015, the Behavioural Insights Team sent letters to 800 GP practices, telling them that other practices were recommending the use of antibiotics in fewer cases. (There is no evidence presented to determine if this was actually true, and judging by the template letter, it’s highly unlikely that it was true.)

The nudge method employed is called ‘social norming’, which operate as a kind of community enforcement, as norms are unwritten rules that define ‘appropriate’ behaviours for social groups. We tend to conform to the expectations of others. Changing perceptions of norms alters people’s expectations and behaviour.

Understanding norms provides a key to understanding social influence in general and conformity in particular. The Conservatives have traditionally placed a significant emphasis on social conformity.

There are ‘hotspots’ where more antibiotics are prescribed. However, the fact that these places tend to be some of the most deprived areas of the country strongly hints that there are underlying socioeconomic factors at play that cannot be solved with a nudge or prod. Research indicates that community socioeconomic variables may play a significant role in sepsis-attributable mortality, for example.

Social problems such as poverty and inequalities in health arise because of unequal distributions of wealth and power, therefore these problems require solutions involving  addressing socioeconomic inequality. As it is, the government is unprepared to spend public funds on public services to redistribute resources.

The behavioural study did not include any consideration of socioeconomic variables on rates or severity of infection, or types of infection.

The idea that ‘changing the prescribing habits in hospitals’ and GP surgeries will impact on antibiotic resistance is based on an assumption that doctors over prescribe antibiotics in the first place. There is no evidence that this is the case, and it’s very worrying that anyone would think that targeting doctors with behaviourally-based remedies will address antibiotic resistance and assure us, at the same time, that antibiotics are actually prescribed when appropriate, and tailored, ensuring the safety and wellbeing of the patient, rather than being prescribed according to arbitrary percentage norms distributed by behavioural economists.

The trials did not include sufficient data regarding clinical detail or diagnostic uncertainty that might justify antibiotic prescribing in individual cases.

One of the nudge unit team’s key aims is to design policies which reduce costs. They say: “The solution to the problem of AMR is not just to produce new and better drugs – that takes time, and a great deal of money. We must also reduce our use of antibiotics when they are not needed. Sadly, it seems that they are used unnecessarily twenty percent of the time in the UK”.

The various Nudge Unit reports on behavioural strategies that target doctors don’t mention any follow-up research to ensure that the reduction in antibiotic prescriptions did not correlate with an increase in the severity of infections or poor outcomes for patients. In fact one report highlighted that those who were admitted to hospital because their condition deteriorated were excluded from the trial, as they no longer met the inclusion criteria. That effectively means that any adverse consequences for patients who were not given antibiotic treatment was not reported. And that matters.

The authors say “We as the authors debated at length as to whether we should emphasise the fact that 80% of the prescriptions are being used in necessary cases.”

There is no indication of how ‘necessary cases’ are determined, and more to the point, who determines what is a ‘necessary case’ for antibiotic treatment. Furthermore, the report uses some troubling language, for example, doctors prescribing antibiotics ‘above average’ were referred to more than once as the “worst offenders.” However, as I’ve already touched on, patients needs may well vary depending on a range of variables, such as the socioeconomic conditions of their community, and of course, complex individual comorbidities, which may not be mentioned in full when doctors write up the account for the prescription.

Sepsis, which may arise from any kind of infection is notoriously difficult to diagnose. It is insidious and can advance very rapidly.  It’s even more difficult to determine when a patient has other conditions. For example, sepsis can arise when someone has flu. That happened to me, when I had developed pneumonia without realising that I had. It’s standard practice for paramedics to administer a broad spectrum antibiotic and intravenous fluids to treat suspected sepsis and septic shock. This can often save lives. Sepsis kills and disables millions and requires early suspicion and antibiotic treatment for survival.

Once the causative agent for the infection is found, the IV antibiotics may then be tailored to treat it. The wait without any treatment until a firm diagnosis is potentially life-threatening. But the biochemical tests, such as CRP, and X-rays take time.

Treatment guidelines call for the administration of broad-spectrum antibiotics within the first hour following suspicion of septic shock. Prompt antimicrobial therapy is important, as risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics. This time constraint does not allow the culture, identification, and testing for antibiotic sensitivity of the specific microorganism responsible for the infection. Therefore, combination antimicrobial therapy, which covers a wide range of potential causative organisms, is tied to better ‘outcomes’.

In the trial, behavioural economists refered to medical notes, and if there is no diagnosis, the necessity of the prescription is then questioned. Knowledge of complex medical histories may also influence doctors’ decisions, and this may not have been mentioned on medical record. A cough and breathlessness is a common symptom influenza. However, a patient with a condition that compromises their immunity, or someone who needs immune suppressants, for example, is rather more at risk of developing bacterial pneumonia than others, and someone with COPD or asthma is also at increased risk.

If a person dies because treatment was not given promptly in high suspicion cases of severe infection and sepsis, who is to be held accountable, especially in a political context where treatments are being rationed and prescriptions are being increasingly policed?

It’s also worth bearing in mind that massive doses of antibiotics are added to livestock feed as a preventative measure and to promote growth before the animals are slaughtered and enter the food chain. Using antibiotics during the production of meat has been heavily criticised by physicians and scientists, as well as animal activists. The pharmaceutical industry is making billions annually from antibiotics fed to livestock, which highlights the perverse incentives of the profit motive and potentially catastrophic impact on humans. It is estimated that between 70 – 80 percent of the total of antibiotics used around the world are used within the animal farming and food industry. No-one is nudging the culprits.

The potential threat to human health resulting from inappropriate, profit seeking antibiotic use in food animals is significant, as pathogenic-resistant organisms propagated in these livestock are poised to enter the food supply and could be widely disseminated in food products.

Antibiotics used on farms can spill over into the surrounding environment, for instance through water run-off and slurry, according to a report from the UN’s environment body, last year, with the potential to create resistance to the drugs across a wide area.

In 2013, researchers showed that people who simply lived near pig farms or crop fields fertilized with pig manure are 30% more likely to become infected with methicillin-resistant Staphylococcus aureus bacteria.

#### Cash for care – rationing referrals to hospital consultants and diagnostic testing

It was announced in April this year that General Practitioners (GPs) across England will be able to “better manage” hospital referrals with a “digital traffic light system” developed by the Downing Street policy wonks. This nudge is designed to target the ‘referral behaviours’ of GPs.

GPs are being offered cash payments as an ‘incentive’ to not refer patients to hospitals – including cancer patients – according to an investigation by Pulse, a website for GPs.

Furthermore, a leaked letter sent by NHS to England to Clinical Commissioning Groups (CCGs) and seen by Pulse magazine last year, asks that all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals.

A “clinical peer review of all referrals from general practice by September 2017”, will be required, the letter said.

To ‘incentivise’ the scheme, the letter said that there will be “significant additional funding” for commissioners that establish peer-led policing schemes. It added that it could reduce hospital referral rates by up to by 30 per cent. NHS England said that they want to introduce the “peer review scheme” whereby GPs check the referrals of one another to ensure they are ‘appropriate’. However, experts warn this increasingly Kafkaesque layer of bureaucracy could lead to more problems and possible conflict with patients’ safety and standard of care.

In a trial of the nudge scheme, four NHS clinical commissioning groups (CCGs) have been using “profit share” initiatives to ration care, to help them ‘operate within their budgets’. Clinical Commissioning Groups hold the budget for the NHS locally and decide which services are provided for patients.

Through this scheme, GPs are told they will receive up to half of the money that is saved by fewer patients going to hospitals for tests and treatments.

So to clarify, surgeries are being offered financial ‘incentives’ for not sending patients to hospital to save money, that is then reinvested in part to implement further rationing of healthcare. The move has been widely condemned as a “dereliction of duty” by the community of medical experts and professionals. Referrals to consultants often involve important diagnostic procedures, therefore there is often no way of knowing for sure in advance of the referral whether or not it is “warranted”.

The NHS has had ‘referral management centres’ in place for many years.  However, last year they were at the epicentre of a scandal when it was revealed that the use of these centres has increased 10-fold over recent years. Furthermore, the centres are privately run and extremely expensive to employ, diverting funds that could simply be spent on patient care.

Moreover, those who were reviewing the referrals were also found to have varying levels of clinical knowledge, and so were not always able to correctly identify which referrals were ‘necessary’. They were also extremely inefficient as patients were forced to wait a long time for appointments.

The Pulse investigation into referral incentive schemes being run by NHS clinical commissioning groups (CCGs) across England found some regions offering GPs as much as 50 per cent of any savings they can make. The “profit-share” arrangements mean practices stand to benefit financially by not sending patients for treatment or to see a specialist.

Hospitals are paid for operations and other activity, so by sending patients to cheaper services run by GP practices – such as diabetes and pulmonary clinics – or by keeping them out of hospital altogether, practices can increase the size of savings. GPs are not paid per procedure. Rather, they receive a single payment when each patient is registered with them.

Currently, when doctors are referring patients for appointments with hospital consultants, the nudge – in the form of a “Capacity Alert System” – operates by displaying a red light next to hospitals with lengthy waiting times, and a green light next to those with more availability, on the system.

The system underwent two trials in north-east and south-west London over the winter. During these pilots the number of referrals made to overburdened hospitals was reduced by 40%, while those made to hospitals with ‘spare capacity’ rose by 14%, according to NHS England. There was no comment made regarding the impacts of the scheme on patients’ health.

GP leaders have also said it is “insulting” to suggest doctors are sending patients to hospital arbitrarily, and raise significant conflicts of interest.

“Cash incentives based on how many referrals GPs make have no place in the NHS, and frankly, it is insulting to suggest otherwise,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs.

Of course, it’s important to take measures to ensure that GP referrals are appropriate and high-quality, but payments to reduce referrals would fly in the face of this, and erode the trust our patients have in us to do what is best for them and their health.”

The NHS has been squeezed for increasingly drastic ‘efficiency savings’ in the past eight years. It’s absurd, however, that a huge amount of money is being spent on restricting access to healthcare, rather than on simply adequately funding healthcare provision.

Dr Peter Swinyard, chair of the Family Doctor Association, said the profit-share schemes were “bizarre”, adding: “From a patient perspective, it means GPs are paid to not look after them.

“It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.”

Meanwhile, NHS Barnsley CCG has identified a £1.4m funding pot to pay its practices if they achieve a reduction in referrals to specialties, including cardiology, pancreatic surgery, and trauma and orthopaedics.

The CCG said the 10 per cent target was “ambitious but achievable”.

Last year it was discovered that the NHS has to spend £1.5 billion in legal costs when patients don’t get what the standard of care expected and pay for from their healthcare providers. In 2015/16, there was a 27% increase in the number of claims and a 72% increase in legal cost, which amounted to £1.5 billion.  With the amount of money that the NHS is spending on legal costs for medical blunders, the NHS could have paid for the training of more than 6,000 doctors. Or eased the rationing of essential healthcare provision.

The purpose of the NHS has been grotesquely distorted: it was never intended to be a bureaucratic gatekeeping exercise that rations healthcare. The purpose of all public services is to provide a public service, not ration provision. Such is the irrationality of the government’s ‘market place’ and ‘profit over human need’ narrative.

Dr Eric Watts, a consultant haematologist for the NHS, says that the British government couldn’t care less about the fall of the NHS. He said, “This is a triumph of secrecy and implacable lack of care about the NHS by a Government determined to watch it fail then fall.”

One CCG told Pulse“Ensuring treatment is based on the best clinical evidence and improving historical variation in access is essential for us locally.

“Financially, it is an effective use of local resources which will improve patient experience and outcomes and increase investment in primary care in line with the Five Year Forward View commitments.” Those ‘commitments’ are the increasing implementation of cuts to healthcare provision and funding.

Cuts to care may well improve financial ‘management’ but it cannot be claimed that healthcare rationing “improves health outcomes” for patients. That flies in the face of rationality.

NHS England also said last year that funding will be available for CCGs to start “peer review schemes”, where GPs police each other – checking that their colleagues are referring ‘appropriately’, but it is not clear what it thinks about direct payments linked to cutting referrals.

The “Cash for Cuts” investigation, by GP publication Pulse, asked all 207 CCGs in England about their processes for cutting referrals. Of the 180 who responded, 24 per cent had some kind of incentive scheme aimed at lowering the numbers of referrals.

This included payments for getting GPs to “peer review” each other’s referrals or other strategies.

Dr Chaand Nagpaul, from the British Medical Association (BMA) has  also criticised the nudge scheme. He says “It’s a blunt instrument which is not sensitive to the needs of the patient and is delaying patient care.

“It has become totally mechanistic. It’s either administrative or not necessary for the patient. It’s completely unacceptable. Performance seems to be related to blocking referrals rather than patient care.”

The CCGs have defended the schemes, saying that at the time they were pushed through, the NHS was struggling through the worst winter ever in its history and had not been able to hit target waiting times since 2015. The CCGs have said that the scheme is only to help reducing ‘unnecessary referrals’ and therefore improve outcomes for ‘genuine patients’, and not to reduce numbers overall. Who decides which patients are ‘genuine’, and on what criteria?

Dr Dean Eggitt, who is the British Medical Association’s GP representative for Barnsley, Doncaster, Rotherham and Sheffield, also disagrees with the scheme.

“The scheme is unsafe and needs to be reviewed urgently,” he said.

The BMA’s GP committee have said that it had raised concerns nationally where CCGs have set an “arbitrary target” for reducing referrals.

Before Christmas, Jeremy Hunt, the Health Secretary, announced that he wanted hospitals to find another £300m in savings on basic items like surgical gloves and bandages, and a long-awaited pay rise for nurses is contingent on staff boosting “productivity”.

A Department of Health and Social Care spokesperson said: “Patients must never have their access to necessary care restricted  – we would expect local clinical commissioning groups and NHS England to intervene immediately if this were the case.”

I’ve asked NHS England whether it would be reviewing cases where GPs stand to profit financially for not referring patients, along with others, but I have had no response at time of this publication.

The NHS was founded on the principle of free and open access to healthcare provision for everyone. The nudge schemes I’ve outlined have introduced ‘perverse incentives’ that prompt GPs to ration health care. I have argued elsewhere on many occasions that nudge and the discipline of behavioural economics more generally is technocratic prop for a failing  political and socioeconomic system of organisation – neoliberalism. Rather than review the failures of increasing privatisation and ‘competition’, the government chose to deny them, applying increasingly irrational ‘solutions’ to the logical gaps in their ‘marketplace’ dogma.

Yet it is blindingly clear that citizens needs and their human rights are being increasingly sidestepped by the absolute prioritisation of the private profit incentive.

Nudge isn’t about ‘economics theory and practice adapting to human decision making’, as is widely claimed. It isn’t about remedying ‘cognitive biases’. It isn’t about people making ‘flawed decisions’.

It’s about holding citizens responsible for the problems created by a flawed socioeconomic model. It’s about a limited view of human behaviours and potential, because it frames the poorest citizens in an increasingly unequal society as ‘failed entrepreneurs’. Those members of the public who need to access public services are increasingly being portrayed as an economic ‘burden’. As such, nudge places limitations on and replaces genuine problem-solving approaches to public policy.

Nudge is about authoritarian governments using a technocratic prop to adapt human perceptions, behaviours and expectations, aligning them to accommodate inevitable  catastrophic social outcomes. These outcomes are symptomatic of the failings and lack of rational insights of wealthy and powerful neoliberal ideologues, who are determined to dismantle our public services. Without the consent of the majority of citizens.

The NHS was never safe in his hands. The company he keeps has made sure of that.

I don’t make any money from my work. But if you like, you can support Politics and Insights and contribute by making a donation which will help me continue to research and write informative, insightful and independent articles, and to provide support to others who are vulnerable because of the impacts of government policies. The smallest amount is much appreciated, and helps to keep my articles free and accessible to all – thank you.

# Nudge and neoliberalism

I’ve been criticising nudge and the closely related discipline of behavioural economics for a few years, sometimes with an international audience (see, for example: The connection between Universal Credit, ordeals and experiments in electrocuting laboratory rats.)  Nudge has increasingly seen by governments as a cheap and effective way of achieving social political goals in an era of austerity.

I have several objections to the “behavioural turn”; some are to do with its impact on democracy, others are to do with its class contingency: poor people are disproportionately nudged, and without their consent. When I say ‘disproportionately’, I mean almost exclusively.

Over the last seven years, behavioural economics has come to be seen as something of a technocratic fix for a failing and overarching socioeconomic system. However, it has more in common with PR, marketing and advertising that psychology or economics. It’s part of the ‘sales pitch’ for neoliberalism, which is already a sold out event.

Behavioural economics epitomizes an era in which politics is concerned chiefly with saving money and combating the symptoms rather than the causes of growing social inequality. Nudges may serve to make poverty infinitesimally more bearable for the government, who can say that they are doing something to ‘solve’ poverty, but certainly not for the poorest people. When you zoom out, you see clearly that exactly nothing is being solved at all. At best, nudge is like persuading a person to learn how to swim in a clean and tidy swimming pool, and them throwing them back into a maelstrom out at sea.

The poorest citizens are targeted with punitive, heavily bureaucratic policies and an administrative authoritarianism, while wealthy people get the freedom to do as they please, and a rewarding form of state libertarian socialism, where the regulation book is ripped up. Unaccountable private companies design nudge strategies for profit, politicians and civil servants learn them and become board room, arm-chair psychologists, experimenting on ordinary citizens to find ways of not paying out for public services. All without the publics’ consent.

What could possibly go right?

The government and their small army of behavioural economists argue that citizens’ characters, cognitive ‘limitations’ and ‘flawed’ decision making is the root cause of poverty and creates inequality, so handing over money every year to poor people is akin to “treating the symptoms, but ignoring the disease.” Margaret Thatcher, the High Priestess of neoliberalism, once called poverty a “personality defect.”

However, this narrative is based on assumption and fails to take into account the possibility that people’s decisions, behaviours and circumstantial problems are not the cause but the consequences of poverty. Giving poor people more money might well just genuinely work wonders, because simply having too little is THE problem.

Nudge is an authoritarian prop for a failing neoliberal ideology and policies. Most citizens don’t benefit from a system founded on accumulation by dispossession – a concept presented by David Harvey, which defines the neoliberal capitalist policies in many western nations, from the New Right Thatcher era to the present day, as resulting in the centralisation of wealth and power in the hands of a few, by dispossessing the public of their wealth, public services and land. And increasingly, their autonomy, as public perceptions and behaviours are being aligned with politically determined neoliberal ‘outcomes’. It’s a vicious cycle – a maelstrom.

Nudge is politically ‘justified’ by a draconian, ideological framework of beliefs, partly based on Victorian meritocratic notions of ‘deserving’ and ‘undeserving’. One theme is that poor people lack the qualities or capacities to be economically competent, and simply make the ‘wrong’ choices. But in a system where everyone competes for resources (as well as a democratic voice, government attention and funding), not everyone is permitted to be wealthy. That is the nature of ‘competition’. There is no such thing as ‘trickle down’ either. Wealthy people

Furthermore, being poor isn’t particularly lucrative, in fact poverty itself tends to be accumulative. Poor people are financially penalised and economically excluded. Poor citizens can’t get loans when they need them, unless they are prepared to pay eyewatering interest rates, of course. Pay as you go metered utilities – gas, electric and water, for example – tend to cost rather more than a monthly or quarterly direct debit. Poor people who get into debt with utility companies tend to be coerced into having payment meters fitted, as they are considered at ‘risk’ of defaulting on payments by big businesses.

It’s somehow become obscenely normal to charge poor people more money than wealthy people for the same services and utilities. I’ve yet to hear of a poor person who became less poor because they are being punished by having more money taken from them.

However, being wealthy is very lucrative; it’s the gift that keeps on giving. This discrimination has been dressed up carefully with a political narrative, using terms like “incentives”. For wealthy people, a reward of more money is apparently an ‘incentive’ to just keep on being wealthy.

Poor people, however, seemingly require a different form of ‘incentivisation’. They need to be told that it’s ‘wrong’ to be poor, and that it is their own fault, rather than the consequence of a prejudiced and discriminatory government and their flawed, prejudiced and discriminatory policy designs. In a so-called meritocratic system, it follows that wealthy people ‘deserve’ their wealth – even though at least one third of them simply inherited it – and poor people deserve to be poor. If it wasn’t for the myth of meritocracy, inequality and burdening those in poverty with a sense of shame and personal failing would be considered abhorrent. However, neither neoliberalism nor it’s PR and strategic communications agent, behavioural economics, are drawn from the philosophical well of human kindness. They came to life in the degenerative, dry ruins of once civilised societies, marking a Fin de Siècle of  late capitalism.

The socioeconomic system of organisation – neoliberalism – eliminates the possibility that everyone can ‘win’, since neoliberalism is itself founded on competitive individualism, which permits only a few ‘winners’ and many more ‘losers’. The existence of absolute poverty in a wealthy country is ample evidence of a fatally flawed system, so the government uses a rhetoric of a myth – meritocracy – to justify the status quo, blaming citizens’ ‘behaviours’ and ‘attitudes’, rather than recognising the real problem and changing the system, which generates inequality from its very core.

So poor people are penalised for being poor by being incentivised’ by punitive economic sanctions that entail losses from the little money they have. This is so appallingly cruel, because scarcity completely consumes people. It eats away at human potential and stifles possibilities. And removes choices.

The patronising ‘paternalism’ of a government that assumes it ‘knows what is best’ for people – punitive nudges delivered by a group of privileged, powerful and prejudiced elitists – is doomed to fail. The key reason is that being poor means having less choice to start off with. Poor people don’t act on available choices because they can’t. They have none. They are compelled to act on necessity.

Maslow’s hierarchy of needs outlines that our most basic needs are biological, and meeting these needs is a necessity for survival. There isn’t a ‘choice’.

Taking money from poor people is simply cruel and barbaric. It reduces ‘choices’ and increases necessity and desperation.

If we can’t meet our fundamental needs, we can’t meet higher level psychosocial needs either – the ones that do entail choices about our lives. Poverty has got nothing to do with making “irrational choices” at a personal level. It’s got everything to do with being left with NO choices.

There is a world of difference between ‘choice’ and ‘necessity’. It is time the government and the technocratic behavioural economists busy propping up a failing system recognised and acknowledged this. People are poor because we have a system that diverts available resources away from them, hanging them out to dry. Until that fundamental fact is addressed, nothing will change.

It’s time for a serious and open political debate about inequality, the limits of nudge, democracy and the fundamental failure of neoliberalism. It’s time to stop blaming poor people for poverty and inequality.

Related

The connection between Universal Credit, ordeals and experiments in electrocuting laboratory rats

A critique of benefit sanctions:  the Minnesota Starvation Experiment and  Maslow’s Hierarchy of Needs

The benefit cap, phrenology and the new Conservative character divination

Stigmatising unemployment: the government has redefined it as a psychological disorder

I don’t make any money from my work. But you can make a donation if you wish and help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.