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We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain.
This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation.
Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not ‘work ready’, particularly if recruited through pain services.
A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.
The chapter examines the changes to the welfare state needed in the post-pandemic world, arguing that, despite its current popularity, a Universal Basic Income is not the right way forward. It will expose the risks of this as a panacea for economic and social ills and argue that we need to focus instead both on devising a fit-for-purpose safety net and restoring high-quality universal public services.
It will look at the loss of dignity and security that has resulted from the inadequate payments and deliberate administrative delays of the current Universal Credit regime and at how this has accentuated child poverty and in particular child food poverty during the pandemic. It will debunk claims that the £20 rise in Universal Credit is a ‘generous’ response and argue for a minimum income commission to advise on the future calculation as the Low Pay Commission does for the minimum wage.
It will conclude by putting the case for renewed investment in education and training, health, housing and digital access and argue that care – both childcare and care of the elderly – must now be integrated into our welfare state, reversing the historic ‘male breadwinner’ model of welfare support.
This chapter introduces the idea of an empowering state – one that provides its citizens with protection from vulnerabilities, resources to achieve their potential, and access to full participation in democratic institutions and decision-making. It argues that the last forty years have instead seen a disempowering state with many excluded by poverty and lack of opportunity, while for others active citizenship and participation were stifled. It contrasts the negative liberty of a neoliberal state – in which wealthy people and corporations are accorded freedom from interference and regulation – with the positive freedoms of a nurturing state – one that provides the wherewithal for each individual to achieve their potential.
It elucidates the many strands of an empowering state, beginning with the need for everyone to commit to making a fair contribution, rather than seeking ways to evade responsibility, and setting out the case for a far more progressive tax system than the one we currently have (which is shown to be essentially regressive). It discusses the need for greater democratic accountability and citizen engagement, with examples from pioneering local initiatives. Finally, it argues that protecting our natural environment and mitigating climate change require the support of an empowering state.
This chapter argues that an empowering society that nurtures its individual citizens and protects our environment rests on seven mutually supporting pillars, based on the values, behaviours and policies that the book has advocated, drawn from history. These will be crucial in creating a society that works for all, as we build forward from the pandemic, giving us the robustness and resilience that we need to face an increasingly uncertain future.
The seven pillars are:
1. A Nurturing State: Respect and inclusive support for all
2. Ethical Capitalism: Working with business to redefine our values
3. Fair Contributions: Full participation by the prosperous
4. Open Public Discourse: Enabling all voices to have an equal hearing
5. Measuring What We Value: Signalling the changes we need
6. A Sustainable Future: Responsible stewardship of our planet’s resources
7. Participatory Politics: Reviving democracy and civic engagement
After the Virus is a book about history and policy. Events such as revolutions and pandemics reveal – like an X-ray – what is going on beneath the surface in a particular society at a particular time. The huge stresses they cause suddenly make starkly visible the damaging effects of the power relationships and embedded inequalities that are already there but too often ignored. The introduction argues that we are now at such a moment of revelation, when people’s political imaginations can be engaged in new directions.
It explains why the reduced investment in our social fabric over the last forty years of a disempowering neoliberal state left us unable to respond effectively when COVID-19 arrived, arguing that the stresses created as a result produced a pandemic that was anything but levelling. Those most at risk were the poor, many with pre-existing health problems, frequently working in exposed front-line roles while others stayed safely inside. COVID-19 was a syndemic. It was not just an infectious disease to be controlled by cutting lines of transmission. It was a super-toxic coming together of a deadly respiratory illness, with latent, non-communicable health conditions (heart disease, diabetes and obesity) that interacted with embedded social inequality.
This chapter explores the rapid increase in wealth and income inequality and the doubling of child poverty during the Thatcher decade, 1979–90, when neoliberalism rose to ascendency. It looks at how this sapped the population’s resilience as less obvious but equally pervasive inequalities of health and economic opportunity took root, with cuts to public services including education, public health and adult social care ratcheted up during the post-2010 austerity. It will present evidence that inequality reduces economic growth, harms children’s life chances and undermines social cohesion, while the super-rich do disproportionate environmental damage.
The chapter will then show how those who need to fall back on the social safety net to claim Universal Credit and its predecessor benefits have been subjected to relentless cuts in entitlements, a four-year benefit freeze and a five-week waiting period that pushed people into reliance on food banks and plunged many into permanent debt. It will conclude by looking in further depth at why, in the light of all of this, COVID-19 was anything but levelling in its impact, as so many people had little or no savings to cushion them and were unable to afford to take time off sick or to self-isolate.
This chapter looks at why the UK was so lacking in resilience when COVID-19 struck. It will examine the corrosive narrative of neoliberalism, which holds that the state is an unwelcome intrusion into people’s lives and the economy, showing how the resulting deregulation and financialisation of the economy replaced productive value creation with exploitative value extraction.
It will detail the cronyism that built up as a relationship of mutual dependence between politicians and the wealthy developed and describe the lack of transparency as pandemic contracts were let that racked up enormous bills but often failed to deliver, spectacularly so in the case of the £37 billion track and trace system.
It will then examine the public spending cuts and damaging reorganisation of the NHS and public health functions after 2012, which left the sector unable to respond effectively to COVID-19. In the rush to free up beds, 25,000 elderly people were discharged into care homes with instructions that negative COVID-19 tests were ‘not required’. Deaths in care homes in the pandemic became a national scandal, both COVID-19 deaths and many other ‘unexpected’ deaths as a result of what appeared to be a systematic withdrawal of normal medical care.
With the chancellor apparently committed to a future balancing of the books, this chapter looks at what this means for future fiscal policy. It details the pressing future spending needs as we build back from the pandemic, address the much discussed ‘levelling up’ of our country and face up finally to the costs of an ageing population. It shows that there is a clear appetite for spending more on public investment and services, even if this means higher taxation. This has been apparent in survey data for decades, although receives precious little media coverage.
While tax rises are not appropriate during the COVID-19 recovery phase, there nevertheless needs to be a conversation about how to support a future more active public sphere. Measures already announced to freeze public sector pay and increase income tax thresholds affect ordinary workers. The case is put that there should instead be a radically revised approach to wealth taxation, addressing anomalies in how capital gains and income are taxed and tapping into the enormous rise in household wealth during the neoliberal years, now widely seen as unfair. Newly published research shows this can raise money just as effectively as increases in income tax or VAT.
The chapter begins by detailing the massive economic support packages announced as the first COVID-19 lockdown was imposed and the accompanying promise to provide the NHS with ‘whatever it takes’. It shows how Conservative small-state ideology was jettisoned and a ‘magic money tree’ found that pushed up the annual budget deficit from £55 to £355 billion, 17 per cent of GDP. It will suggest that, in the light of this, people might question how necessary the preceding years of austerity had been, arguing that austerity in fact lowered economic growth, failed to pay down any of the massive debt from the financial crash and was based on flawed analysis.
It will strongly refute the idea that the unprecedented costs of the lockdown must now be ‘paid for’ and the reckoning must come soon. Using detailed historical comparisons and arguments about the peculiar opportunity that negative real interest rates provide, it shows that we can accommodate a rise in the national debt without yet more austerity cuts to public services. The costs of the pandemic response can and should be treated in the same way that the one-off costs of war were in the past – paid off over the long term.
This chapter sets out how Elizabeth I’s extraordinary Poor Laws brought into being the world’s first collectivist-individualist society, a unique English political and moral achievement that mandated community support for orphans, widows, the infirm and sick, the old, the involuntary unemployed and single mothers and their children. It will show how this nurturing welfare system protected England from the scourge of famine – that other devastator of populations after plague – such that the English were free of large-scale famine more than 150 years earlier than the rest of Europe. It also helped power England’s exceptional economic growth, supporting a mobile workforce to develop secure in the knowledge that they would be supported if times were hard.
It details how these Poor Law provisions were misguidedly overturned in 1834 by the new, more exclusively individualist economics and utilitarianism of the nineteenth century before returning, over a century later, with the founding of the post-war Beveridge welfare state. This saw a collectivist-individualist balance restored in full all across society, a Golden Age of growth with a comprehensive welfare system funded by progressive taxation and leaders of enterprise incentivised to consider long-term returns alongside the welfare of their workforces and communities.
This final chapter argues that there is a far greater crisis heading our way. What is far worse than nature ‘biting back’ with a deadly virus is that we now live with the disturbing knowledge that the natural world that sustains us all is liable to collapse. COVID-19 is not a ‘once in a hundred years’ event that we can soon confine to folklore. It is a warning shot across our bows, alerting us to the seriousness of the imminent challenges of climate change and the escalating crises of nature and social inequality. These cannot be addressed unless we discard the neoliberal straightjacket and revitalise a nurturing society.
It is often considered that the industrial revolution was Britain’s most unique contribution to world history. However, that achievement emerged from a society and economy that had enjoyed unprecedented success due to its adoption since c.1600 of the policies, principles and practices of collectivist individualism, a more valuable British legacy to the world than the unbalanced individualism adopted in the subsequent industrial revolution. It is a legacy that urgently needs to be rediscovered to enable us all to find the commitment to each other needed to meet our imminent challenges. Coexistence, anti-exploitation and nurturing are the moral codes of the collectivist-individualist ethics, a morality of giving, not taking.
This chapter challenges the idea that there is a natural human condition of selfishness, as personified by the figure that has dominated economic theory for so long – ‘rational economic man’. It shows how the calculations and trade-offs that this sort of thinking promotes jar with our socially produced instincts and are entirely inappropriate morally. It presents evidence that refutes any such easy correspondence between this abstract Homo economicus and our actual motivations and behaviours.
It then looks back at our history to show that it has been moral narratives about who we are and want to be that have driven past transformational change. It uses the examples of the post-war welfare state and the revolution in local government in many of Britain’s major provincial cities during the period 1870–1900 (termed ‘gas and water socialism’ by its detractors) to illustrate this. In each case change was effected because the power elite was, firstly, persuaded of the moral case for action and, secondly, formulated the practical means to resource the major changes envisaged. It draws contemporary parallels with voices highlighting the dangers of escalating inequality and calling for a radical reset of corporate capitalism while questioning our favouring of growth over well-being.