Jam tomorrow? Prospects for the “just about managing” in Britain

On 16^th March 2017, Professor Martin McKee from the London School of Hygiene and Tropical Medicine gave the annual Litchfield lecture in St Luke’s Chapel, Oxford. Martin, like me, is an ardent Europhile and took advantage of the occasion to condemn the way in which the Prime Minister and her “Three Brexiteers” (Davis, Fox and Johnson) are organising – or perhaps failing to organise – this country’s forthcoming departure from the European Union. His quibble was not with the democratic vote that led to the Brexit decision but with the harm that an ultra-hard Brexit, combined with failure to understand or adequately plan for its consequences, is likely to cause to one of the most vulnerable groups in British society: the “precariat”.

The “precariat” is a relatively new and expanding sector of the population whose lives are precarious as a result of multiple interacting factors: low skills, low wages, harsh working conditions, economic insecurity, inadequate housing, poor health and limited social networks (see Guy Standing’s book ‘The Precariat’ and the Human Development Report 2014 for more detail). They account for around one-fifth of the adult population of the UK. 

As a general practitioner, I encounter members of the precariat frequently: they typically work on zero-hours contracts for companies like Uber; they live in short-lease, privately rented accommodation that is damp, cramped and a long way from green spaces (but only a tiny fraction of them have sufficient points to have a realistic chance of ever getting re-housed); they are often on chronic disease registers for conditions like diabetes, high blood pressure or depression – but they rarely ask for sick notes because they lack de facto employment rights; their children attend frequently with respiratory infections – and so on. They are not the traditional poor (for example, they are typically “in work” and may identify as “lower middle class” rather than “working class”), but they have remarkably little hope for a better future and very limited financial, human or social resources to draw upon when serious life events strike.

Martin argued that the “precariat” is expanding at an alarming rate (though this is difficult to track since government by and large refuses to recognise this sector, let alone define or monitor it). He presented comparative data from countries with more progressive welfare systems (notably Sweden) and less progressive ones (for which he cited Spain, the UK in recent years and the USA under Trump) to support his argument that regressive political measures are associated with a significant deterioration in the health of individuals living in precarious circumstances and vice versa.

The introduction of a recommended national minimum wage in 1999 in the UK, for example, significantly reduced the incidence of depression in those who benefited from it over the next few years – but had no effect on natural controls whose employers failed to comply with the recommendation.  Conversely, during the 2008-10 financial crisis, there was a significant increase in male suicides in the UK, and an estimated 40% of these suicides could be attributed to rising unemployment.  

Perhaps we can’t stop people losing their jobs – but state support, training and guidance to the newly unemployed could greatly lessen the impact of redundancy. If nothing else, such measures would give the message that someone cares.  But in the UK, argued Martin, there is little evidence of the state “caring”. Rather, as he showed recently with Oxford colleague Professor David Stuckler, the unemployed and chronically sick are increasingly required to jump through a series of ever more complex hoops, officially described as “sanctions”, to gain eligibility for benefits.  They found that as sanctions increased, the number of people claiming benefits fell, but this was not associated with an increase in return to work – a finding that the government recently found so politically unpalatable that they accused the authors (falsely) of using flawed logic and cherry-picking their conclusions.

Martin presented troubling evidence that reductions in housing benefit were associated with significant increases in depressive symptoms in vulnerable individuals; that budget cuts to local authorities (especially in social care and discretionary housing benefits) were linked to increases in homelessness; and that the rise in food bank use was strongly linked to austerity measures in the UK.

In short, rolling back the welfare state is a political choice that harms those living in the most precarious conditions. Government’s implicit claim that such regressive policies are somehow empowering because they prompt people to develop their human capital, get on their bikes and find work have no scientific basis.