The marketisation of public services has been widely discussed by social policy analysts, but what is seldom emphasised in such reports is that this process incorporates a contradiction. On the one hand, marketisation has facilitated welfare state retrenchment, thus enhancing inequalities through maldistribution. Yet, on the other hand, marketisation has helped to bring about emancipation from top-down expertise and the paternalism of welfarist service provision.
This contradiction between creating and dismantling hierarchies comes sharply in view in the mechanism of ‘direct payments’, whose increasing salience amidst austerity-driven reforms of UK social policy calls for a critical examination. According to a report published in November 2015 by the Department for Work and Pensions, ‘[i]n 2013/14, 62 per cent of users of community based services and carers received a personal budget, compared to 56 per cent in 2012/13 and 43 per cent in 2011/12’. Amongst those with a personal budget, nearly one in five received their personal budgets as direct payments.
A direct payment is a form of personal budget in which a specific amount of money is provided by the authorities directly to the user of social care services. This enables the user to have full control over the purchasing of services. The amount is specified following a needs assessment process and the funding is intended to cover the expenses of meeting the user’s eligible needs. The provision of funding, instead of services in-kind, and the opportunity for the user to be in control of the funding is intended to empower the user, transforming him or her from a passive recipient of provider-defined, standardised service solutions into an empowered, autonomous agent (customer) of user-defined, personalised services.
Disabled people have been in favour of direct payments because of its potential to facilitate independent living by enabling disabled people to hire and manage their own personal assistants. Studies of actually existing direct payment schemes in the UK have shown that, for the users, the most beneficial aspects of such schemes – and the ones that sharply distinguish direct payments from traditional forms of disability support – are the ability of the user to choose his or her personal assistant(s) and to control the timing and content of the assistance. In effect, users have reported deeply transformative experiences of newly found freedom.
In order to understand the significance of direct payments for disability justice, one needs to look at the immediate historical background. Historically, the post-war welfare state of the 1950s and 1960s provided social protection to disabled people, but failed to respect their autonomy. Enhanced redistribution ensured that disabled people gained improved access to social care, healthcare and education, but public services were often organised and provided in such ways that disabled users were deprived of choice and control over their lives.
Throughout this period, disability was reduced to an individual and medical problem, to be treated by specialists in special places such as special schools or special enterprises. Many disabled people were confined to residential institutions for social care due to lack of community-based alternatives; home-based support (where present) was either informal (i.e., delivered by relatives and/or friends) or provider-defined and standardised.
Disabled people mobilised in a social movement in order to oppose the welfarist hierarchies and paternalism of the post-war period. In the UK, the disabled people’s movement gained momentum in the 1970s and the 1980s through organisations such as the Union of the Physically Impaired against Segregation, Project 81 and the British Council of Organisations of Disabled People. Disability activists fought against the confining and controlling power of segregated public services such as residential institutions and campaigned for deinstitutionalisation.
The mechanism of direct payments was a logical development of this fight for deinstitutionalisation. In the UK, the disabled people’s campaigning for deinstitutionalisation and direct payments contributed to the passing of the Community Care (Direct Payments) Act 1996. This legislation was supported by the then Conservative government because it advanced its efforts to fight the ‘nanny state’ by developing public service markets – a strategy already codified in the NHS and Community Care Act 1990.
Thus the fight of the disabled people’s movement in the UK for emancipation from patronising relationships and top-down expertise converged with the neoliberal project of undermining an allegedly all-powerful state through market mechanisms. Similar processes happened elsewhere in Europe. For example, the independent living activist Adolf Ratzka recounts how in the 1980s in Sweden, right-wing politicians were more sympathetic to disabled people’s demands for direct payments than left-wing ones: “The conservative parties who had been propagating ‘freedom of choice under own responsibility’ for decades embraced [our demands] wholeheartedly. The Social-democratic and Communist parties, both at that time in the government, reacted mainly negatively interpreting the demand for alternative solutions as a right-wing attack on the public sector.”
Notably, the Swedish Personal Assistance Act of 1994 – which is the Swedish analogue to the British Community Care (Direct Payments) Act 1996 – was similarly adopted during a period of right-wing government in Sweden (1991 – 1994).
But the link between marketisation and disabled people’s advocacy for direct payments is far from straightforward. On the one hand, some disability activists such as Ratzka in Sweden or the Bulgarian organisation that I worked for in the 2000s, the Centre for Independent Living – Sofia, have argued that the mechanism of direct payments works best in the context of developed service markets where service providers compete to attract users with purchasing power. The promotion of market-based competition is expected to increase not only the user-centeredness and quality of provision, but its cost-effectiveness as well.
Yet on the other hand, disability activists and scholars such as Peter Beresford and Jenny Morris in Britain have insisted that the advocacy for direct payments should be decoupled from promotion of marketisation. According to Beresford, the struggle for direct payments in the UK has sought to promote social justice rather than marketisation, and citizenship rather than consumerism. From this perspective, marketisation has been an unanticipated and unintended effect of struggles against welfarist hierarchies and paternalism that needs to be criticised rather than promoted. According to Morris, with its advocacy for direct payments, the disabled people’s movement has facilitated the ascendance of public service markets, which has resulted in a ‘steady undermining of collective responsibility and redistribution’.
The clash between the proponents of marketisation and its critics amongst disability activists is a function of the aforementioned contradiction between, on the one hand, dismantling of welfarist hierarchies, for which marketisation could be an ally, and, on the other hand, preserving publicly provided support, for which marketisation could be an obstacle. In his sense, the disabled people’s movement is currently faced with the difficult task of continuing to criticise welfarist misrecognition of disabled people while simultaneously defending mechanisms of disability-related redistribution.
This task is particularly pressing in the present times of austerity, when maldistribution has been normalised, threatening to undermine years of advocacy and achievements. A recent example is the closure in 2015 of the Independent Living Fund (ILF), a public body in the UK responsible for providing direct payments to disabled people with high-support needs.
The existence and demise the ILF suggests that the welfare state needs to be simultaneously criticised and defended. The context of post-2008 austerity makes it increasingly difficult to recruit marketisation as an ally in the rekindled struggle for disability emancipation. And yet, the principles of independent living have (rightly, in my view) remained integral to contemporary anti-austerity struggles waged by the new wave of disability campaigners.
Teodor Mladenov is Leverhulme Early Career Fellow at King’s College London, Centre for Public Policy Research.
Image by Tom Olin, available online on the website of Action for Access Project.