Yesterday in my blog about new thinking for these times of austerity I described what I termed as ‘the entitlement paradox’:
‘Rising entitlements are a sign of social progress but their maintenance and growth depends on us not treating them merely as entitlements. In other words the sustainability and social value of welfare benefits depends on the existence of a strong work ethic and the sustainability and social value of public services depends on them being seen as collaborations which involve responsibilities for citizens and communities as well as the state’
To underline why this is truly a paradox: I am arguing simultaneously for the defence of entitlement (I don’t want a return to the poor law or access to public services like schooling or health care relying on a patchwork of voluntary organisations) and that such entitlements are unlikely to be sustainable unless we see them not as entitlements but part of social contract requiring of us certain reciprocal attitudes and behaviours (which go beyond obeying the law and paying our taxes).
Understanding this idea in relation to welfare benefits is relatively straightforward. It would obviously be easier to fund such benefits if everyone who could work did work and if those of us who are able to saved up for our old age. The case in relation to public services is easy to state but harder to make concrete either as policy or action.
It is obvious that the effectiveness of health care systems (especially if we see them as being about promoting wellbeing as well as curing sickness) depends on citizens making wise health choices and being good patients. Equally, parental engagement is the single biggest determinant of children’s success at school. But when it comes to what we do about this insight, it is hard to get beyond various limited approaches ranging from the exhortation of public health campaigns, to occasional – usually ineffective – forays into conditionality (home school contracts, for example).
When asked to speak about this (BTW in the light of the collapse of global capitalism I have decided to hold my 2012 rates at my 2011 prices) I refer to something that has happened and something that should happen. The former is the transformation of domestic refuse disposal from a delivery service (the council simply did it) to a co-production (norms and rules on recycling mean most of us spend as much time and effort managing our waste as the council). The latter is my conviction that we need a new reciprocity in child development whereby schools see it as their job to help foster a culture of learning across their locality, and the community as a whole accepts the responsibility for successfully educating and socialising young people.
Today I read a more vivid and subtle example of services as the outcome of reciprocal relationships. Research by Anne Hook and Bernice Andrews found that a significant variable in the effectiveness of psychiatric treatment for depression was whether patients disclosed their true feelings to therapists. Those who hid their feelings – generally because of shame – were much less likely to get a good outcome.
The first lesson is that patients have to use the service responsibly (respecting the therapist’s need for openness) for it to succeed. But – and this is crucial - this lesson can only be learned alongside a second. Over to Dryden Badenoch, who wrote the blog post in which I read the research:
By illustrating the effect of individual client decisions on therapeutic outcome, Hook and Andrews have furthered the argument for routinely considering the client's contribution to the effectiveness of psychological therapies, rather than treating the client as a passive recipient of the 'miracle therapy' or the attentions of the 'super-shrink'.
For those on the traditional left, there is no paradox of entitlement; they think the only problem with welfare and social rights is the will to fund them. It won’t excite those on the radical right; their goal is to dismantle entitlement. But for those to see the paradox, this research study points to part of the long term answer.
We need a gradual, largely bottom-up process in which stronger norms and expectations of citizen responsibility are cultivated alongside changes in professional culture and institutional form. The idea that the social outcomes of public services are the result of relationship not a transaction requires more responsible citizens and more modest managers and professionals.
Such a cultural shift will take a generation. But perhaps one of the good things about the position in which we now find ourselves is that we could become more realistic about change.