Tuesday, 24 September 2013

Drunk tanks, free school meals and universalism

In the past week, a couple of stories caught my eye, as they sparked considerable media attention.  Nick Clegg promised free school meals for all children in their first three years of primary school, and the Association of Chief Police Officers (ACPO) proposed ‘drunk tanks’ for those who were so drunk they were ‘incapable of looking after themselves’.

At first sight, you might think there’s little to connect the two policies, but I’d suggest they’re two sides of the same argument, regarding universalism.  This sparked me thinking about the ideas I'll ramble about in this post.

Daniel Sage has talked about this (relatively) recently over at his blog Knowledge is Porridge.  His argument was that Labour seemed to be moving away from the idea of universal benefits, and suggested that it’s universal services that command support and engage people – think of the NHS, most obviously, but also schools and public transport (especially for pensioners).

Nick Clegg’s free school meals, and Labour’s recent announcement on childcare, can be understood in this light: providing universal services to all children.

However, there’s immediately a potential problem with this initiative being classified as ‘universal’: if we take the unit of analysis as an adult (rather than all children) then it could be argued that the service only immediately benefits those who have children.

I have heard this same argument advanced in all sorts of contexts.  For example, people sometimes complain that their union does nothing for them – which can often be seen as a positive thing if this is because they’ve never had cause to draw on legal support, other funds or the helplines provided.

The idea in the back of people’s minds when they say this is that people should pay for what they use – and this is not the principle behind the NHS or union services.

Examples of this idea in practice might include the suggestion that those who consume particular amounts of alcohol or fatty foods should pay for their own medical treatment, rather than relying on the NHS, because they have caused their own illness.  This is what distinguishes ACPO’s proposed ‘drunk tanks’ from triage models already in place in town and city centres which mean that drinkers aren’t admitted to hospital emergency departments at great cost: the drinkers themselves would face fines to pay for the service they have received.

However, it’s hard to draw the line as to where someone is at fault for their illness.  Thinking of alcohol-related issues specifically, alcohol is understood to distort reasoning through its effects as both an intoxicant and an addictive substance.  For centuries the British legal system has struggled with the issue of how alcohol affects a person’s responsibility, and we still don’t have an entirely satisfactory answer.*

One response to this issue, particularly for those on the left, is to argue that, yes, people are rational and they should take some responsibility for their actions, but they don’t start from equal positions in the game of life.  This can mean in practice an emphasis on cultural or wider structural factors that affect people’s propensity to behave in certain ways.  ‘Lifestyle’ might be a class issue.

This doesn’t in itself undermine the agency or rationality of those who do behave in ways that might be deemed damaging to their health.  The link above about addiction and rationality points to an interview with Carl Hart from Colombia University (I’d also recommend the Q&A on his own website).  His train of thought isn’t to say that crack addicts, being rational, therefore have themselves to blame because they could theoretically make different decisions.  Rather, he suggests: “If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure”.  The whole point is that his experimental work presented crack users with genuine choices – which meant that they often chose something other than crack.

However, these arguments are unlikely to persuade those who have a worldview that emphasises personal autonomy and responsibility – precisely those who are most likely to be opposed to the idea of universalism in the first place.**  Such a worldview, with an emphasis on the market, tends to take something of a moral or natural selection view of life: people sink or swim, win or lose, live or die by their own merits and luck.

And indeed, those on the right may be as tempted as those on the left to argue that ‘lifestyle’ is a class issue – class (or more accurately groupings of people, say chavs, the underclass, the mass) can be mobilised as a negative concept, as much condemning as explaining.

What I want to suggest here is an alternative way of addressing this criticism of universalism.***

In the end, we come back to some ideas from my previous post about risk and population health.

A focus on personal responsibility tends also to mean an opposition to population-wide measures, as these are seen as hurting the ‘responsible majority’.  A targeted approach, according to this ‘consequentialist’ view, seems much fairer.  We should be left to get on with our own decision-making, with the attention directed at those whose actions produce negative outcomes – the doughnut eaters who end up with diabetes.

However, it’s revealing that a standard alternative offered to universal health care is an insurance-based system.  Such an approach highlights the importance of the concept of ‘risk’ in understanding alcohol harm.  Just like those union dues, we pay insurance because we don’t know how likely we are to suffer some form of misfortune.  And in fact, at our individual level, neither does the insurance company – rather, it aggregates the risk in the same way that a government would do in formulating a total consumption model of alcohol harm.

This idea of risk is generally accepted by liberals/libertarians – note Chris Snowdon’s comment on my last post: the government shouldn’t be intervening because the risks are ‘trivial’ at an individual level for the levels of consumption we’re talking about.

But inherent in risk is a lack of certainty.  And such a lack of certainty is hard to manage if you’re a rational actor.  This would be fine if you could be given probabilities of your actions: you pays you money, you takes your choice.  But we’re also told that the advice offered by medical practitioners regarding alcohol consumption is unreliable, with recommended daily consumption guidelines having been ‘plucked out of the air’.  That is, there are no reliable estimates at an individual level for the risks associated with drinking.  It’s precisely this point – that we’re not really able to assess our own level of individual risk – that lies behind population-wide interventions.

Of course one instant response is to say that such theoretical nuances don’t really apply to the reality of serious ‘lifestyle’ related illnesses – the alcoholic or the doughnut eater.  But thinking again of alcohol it’s not that easy to say that there are clear-cut cases.  Not all heavy drinkers suffer from alcohol-related liver disease, for example, – and certainly not cirrhosis – and on the other hand genetic or other compounding factors can increase your risk.  Moreover, there might be no outward warning signs until the liver has been extensively damaged.

That makes rational decision-making about one’s alcohol consumption pretty tough – especially if we are to disregard government recommended limits – which makes it harder to place the responsibility for an individual’s alcohol-related illness entirely at their door.  The alternative, I’d have thought, would be to accept some idea of reasonable risk metrics – and that’s something the temperance movement could perhaps help us with.  Though I’m not sure that would go down too well those opposed to universalism and population-wide alcohol control.

(This argument might apply more to the longer-term health effects of alcohol rather than the immediate ending up in a triage unit at 1am on a Saturday morning, but I’d like to think it’s still worth thinking about in alcohol policy discussions.)

*There are great chapters covering this issue here: http://www.palgrave.com/products/title.aspx?pid=550243

**Notably, the articles I link to above that mention people paying for care related to ‘lifestyle’ decisions are based on comments from individuals associated with Policy Exchange and the IEA, both of which advocate free market solutions to public policy issues – i.e. have considerable faith in models based on an individual rational actor.

***It should also be noted that rational-choice models can acknowledge the importance of context, just like Carl Hart’s model of crack users.  Iain Duncan Smith sees it as his mission to make work pay., his model could be understood as suggesting that people are simply taking rational advantage of an apparently warped system.


  1. Hi Will - thanks for the link! Great post... I'm sure you know this but much of the critical writing on risk differentiates it from uncertainty, which is not felt to be calculable. And for risk you need evidence, numbers, so it becomes a different kind of debate. Of course it's much easier to calculate risk for populations than for individuals, and both actuaries and public health statisticians are careful not to suggest an individual case will neatly fit the probability curve - that's the thing about big numbers. Problem is, that doesn't help if you want to give health advice to the individual...

    The wider issue is, as you say, the idea that we pay in because we will benefit ourselves. This not only demonstrates our inability to think socially but also to think historically - because the first generation to receive the benefits of socialised insurance and welfare could not, obviously, have paid for them.

  2. Thanks James. You're right that I might express things more clearly if I made that distinction in terminology.

    On the individual guidelines point, it's an imprecise science, really, but personally I think the current UK guidelines aren't unhelpful. It's one of those situations that emphasises how all public policy is compromise.

    On the wider universalism issue, I do get worried when politicians start to justify public services in contributory terms, as it undermines the idea of universalism which, even if it shouldn't apply to all services all the time, has some merit.

    This isn't just about universalism; it's about the quality of public debate more broadly. In higher education, I think the debate is devalued by the Russell Group too readily engaging in the economism of BIS in order to win funding. Sure you can gain through arguments on this, but there's more to HE than this, which gets missed, and that has longer-term consequences. (However, that doesn't mean Stefan Collini's arguments make sense...)

    Anyway, enough tangential rambling. Thanks again.