Subsidiarity and the UBI vs UBS debate

This post is a response to Simon Duffy’s critique of a debate between Barb Johnson (from Basic Income UK) and Anna Coote (from New Economics Foundation). Barb Johnson, as the campaigning group she is from implies, supports a Basic Income Guarantee or Universal Basic Income – a sum of money paid to all citizens (residents?) of a country regardless of their income, wealth or work status. Anna Coote supports Universal Basic Services, an idea being developed by the Institute for Global Prosperity at the University College London, and has herself responded to Simon Duffy’s critique here.

I think that much of Simon Duffy’s critique is about the principle of subsidiarity: who gets to decide. I think that this is a separate issue from who pays or how payment is made, and in this blog I try to explain why I think that. Additionally, it is important to understand where a national service is recommended and why: national or public provision is suitable for costs that are substantially higher than an individual’s income (education, healthcare), prohibitively expensive for all but the best-off in society (childcare, housing, social care) or bring substantial external benefits to society (infrastructure, environmental protection). Where national or public provision is unsuitable is for those areas that individuals generally can afford or are expected to be able to afford in a decent society: food, clothes, heating, electricity, hygiene, hobbies and so on.

Firstly, how payments are made. Payment can be made in a variety of ways. Payment can be given by the central government to a provider, or to a user. If given to a provider, payment can based upon how many users they have (GP surgeries), how many actions of a particular type they carry out (hospitals) or how many outcomes they achieve (Work Programme). Or it can be given directly to the individual based upon the assessed level of need (benefits).

Secondly, payment is separate from control. In GP surgeries, decisions are made between the GP and the patient. Patients have some choice over which hospital they use, but unemployed people have no choice over which Work Programme provider they use. Benefit recipients largely have complete choice over how they spend their money. Social care is a mix: some people get direct payments and to some extent choose where that money is spent, but most have little to no control over what is provided and who by.

The issue is not how the payment is made. The issue is about who decides. Patients have choice when the NHS is sufficiently well funded that there are several GP surgeries and several hospitals to choose from within travelling distance. They have choice when the treatment offered includes all that is known to be effective for at least some and is not constrained by finances or time delays. Unemployed people could be given the option to choose between several different employment support providers operating in the same area, rather than having the government choose the provider.

Paying cash directly to users is not a panacea. Benefit recipients have complete control over expenditure of their benefits, but they don’t receive enough to make genuine choices to improve their life. Instead they are forced to choose between necessities – food, heating, hygiene, housing – and people are dying from hunger, homelessness and despair. Social care provides direct payments, but it doesn’t come with control. Healthcare doesn’t provide direct payments, and arguably shouldn’t.

Pain relief is a simple example. Pain relief comes in a variety of forms of widely varying expense. There is the basic paracetamol and ibuprofen which can be bought cheaply from a chemist. There are slightly more expensive stronger drugs – naproxen, co-codamol, paramol – which can also sometimes be purchased from a chemist. Then there are drugs that weren’t originally developed for pain relief, such as amitriptyline (a tricyclic antidepressant) and gabapentin (an anti-epileptic). Low doses of tramadol, dihydrocodeine and codeine, taken in tablet form, are still relatively cheap. But if you need them in a capsule or dissolvable form, then the price can more than double. This is before we start getting into stronger doses and types of opioids, or slow-release tablets and patches like BuTrans and fentanyl.

Pain relief should be prescribed based on efficacy and tolerance of side effects, not on money. If we gave all pain patients the same sum of money to spend as they wished on pain control, there would be some patients with too much money and many patients with far too little. Cost should not be something that the patient has to consider when determining the best treatment; it is the impact on health – the control of symptoms and minimisation of side effects – that matters. Consequently, healthcare is not a suitable area for cash transfers over the direct provision of services.

A properly funded NHS would result in patients able to choose between multiple GP practices based on which is best for them; between different therapies based on what is best for them; and different hospitals based on which is best for them. There wouldn’t be artificial monetary constraints that give too much money to people who do well on cheaper products and too little for those who need services that are more expensive. There wouldn’t be direct payments, but there would be patient choice.

Similarly with childcare and education: parents exercise control when they are able to choose between several state-funded quality services. The state can fund childcare and education on an adequate per-user basis. The providers then have to improve what they offer and ensure that it fits what parents want and children need, if they are to attract users. The local council can monitor the performance of providers of services and ensure that none fall below what is acceptable.

I think the same applies to social care. Social care is constrained by fixed budgets, but it shouldn’t be and nor need it be. It could be funded on a similar basis to the NHS, education and benefits – in accordance with the number of people needing it and their level of need. People should be free to choose the social care that is best for their needs without the constraints of cash payments limiting them to inappropriate, inadequate or insufficient care.

Universal Basic Services isn’t about the ‘well-heeled left’ thinking that they know best. It is about providing adequate funding alongside adequate local and user control, and recognising that cash is not a synonym for control.

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