Universal Basic Income and the NHS

Our care system is close to breaking down and debates about greater levels of funding are being accompanied by the start of some discussions about what else needs to be done.  On the progressive wing, once the shouting from the poorly informed factions dies down, ideas are once again being put forward about Universal Basic Income (UBI). This is interesting but highly problematic as it could constrain the more productive thinking about universal services and even threaten the existing services – and the NHS is the biggest universal service.

UBI can easily be portrayed as a neo-liberal idea.  It pools risks by giving everyone enough income, as of right, to pay for the costs of dealing with their needs whatever they are and whenever they arise.  In one sense you can always buy the services you need in the market. It is predicated on the idea that there are many choices to be made about services and a plurality of supplies – a market where choice and competition reign.  The state provides the money and may regulate the markets.

UBI does free citizens from imposition of solutions by the state and it is empowering at least in the market sense.  It is deceptively simple, socially just, and frees everyone from any stigma about “welfare” or “benefits” and removes the barriers set for assessment of needs and intrusion.  What it (probably) is not is very effective at redistribution of power, wealth or even income.

It is almost certainly impossible in this country because of the way we meet housing needs and deal with long term disability.  If the level of UBI was set so that there was never any need for anyone to need help with meeting housing costs or support for independent living it would be totally unaffordable.  If it is set below this threshold then there would still have to be systems for assessment and payment of other benefits, so it would not be universal.

And a serious additional objection is that it would be individualistic – actually needs are often more complex and involve families (in the modern sense) not just individuals.

Bringing this into the context of the NHS and social care we already have some personal budgets and are trying for more.  Here there is still an assessment of needs, but money is provided as opposed to access to services. This has had mixed results but many on the left are very hostile to the whole idea – even some who also support UBI!

Policy development around care is generally moving towards removal of markets and competition from the NHS and progressively reducing the plurality of supply so there is less private sector intrusion.  For social care the thinking is moving towards making more care free (into the universal service model) and also commencing the long journey to remove at least the worst aspects of private provision of both domiciliary and residential care.  The end state would be some National Care Service on the NHS model; still with some variation in delivery but closer to a publicly provided model.

This is the best way to go, in my opinion.  Moving to UBI and the shift in resources that this implies could destroy the universal service model. And we ought just to mention without further comment Universal Credit!! Be careful what you wish for – basically deceptively simple and sound on principle but impossibly complex when in operation.

Beyond care the case has already been made for universal free education – cradle to grave – not giving out money to allow education to be purchased. A far better housing offer would restore the idea of Council Housing on the old model even if that totally disrupts the current housing market dominated by buy to let ownership and dodgy private landlords.

Looking back, when last in power Labour invested £billions to improve public services and tactically their approach using more “market” type thinking did actually work.  Labour then rightly saw many public service delivery models, especially local authorities, as very poor and unreformable – so we get ALMOS, Academies, Foundation Trusts which are like private organisations but are varieties of unaccountable quangos.

Though this was tactically successful it was strategically dangerous as it further eroded the usefulness of local authorities, demeaned the public sector as provider of services and lost the connection of services to local communities.  Maybe effort was needed instead to make local authorities better and to give them far more funding and control, not less, over how services were provided. We can see in Manchester an attempt to roll back the years and make the local relevant again – let the big issues about WHAT is needed be determined nationally but decisions about HOW services are provided should be as local as possible.

All the recent research tells us that almost all of us are not too far away from needing support at some time in our life.  The systems should be about redistribution of our tax and benefits over a lifetime. Few if any do not get some needs met without payment – we use state education, the NHS, or take the state pension when we reach the threshold.  Bad luck can send illness or redundancy and bereavement or family breakdown can suddenly present a whole raft of needs. Our wider system for supporting everyone has to be founded on universal services; we all pay in based on ability to pay (would be a great idea!) and we can all get help without any intrusion or stigma when we need it.

It will be very hard indeed to remove current UBI- like components of our support system – things like the old age pension or attendance allowance, but this is the right debate to have.  Would it not be better to pool some of the monies paid out in universal cash benefits and replace them with better universal services?

Richard Bourne  21/8/19

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