Tag: Choice architecture

The Healthcare Nudge Tax – Hubert Huzzah

Mary Seacole was a British-Jamaican business woman and nurse who set up the British Hotel in the Crimea during the Crimean War. Not as well known as Florence Nightingale, she essentially spent all of her fortune tending to the British Wounded. She was Florence Nightingale’s copay. There are a wide range of reasons why Seacole ended up going from successful Businesswoman to Poverty but the cost of nursing care was a significant contributor.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is seen, on the Left, as introducing something new to the National Health Service: co-funding and co-payment. This is untrue: whenever someone pays for spectacles, dental treatment or a visit to the chiropodist, that falls, broadly into co-funding-co-payment. There is no need to legislate for these things. What the Bill is seeking to create is something a lot more than simple co-payment.

Seacole paid for treatment and facilities for British Soldiers in Crimea. She lacked the social connections in Britain to do anything other than pay the full economic costs for her efforts. The important point is that Seacole was co-funding and co-paying the Healthcare provisions of Florence Nightingale. Lacking the connections of Nightingale, Seacole was obliged to pay in full, up front, the market price of nursing care. Unlike Nightingale, Seacole was not economically supported in delivering nursing care. When the Crimean War ended, Seacole came to Britain and was both well known and sympathetically received but poor. Her fortunes were only really restored by patronage and public subscriptions to her.

Sir Christopher Robert “Chopper” Chope OBE son of a Judge, pioneered the sale of Council Houses – with such aggression he became known as Chopper. As Chairman of Conservative Way Forward he has been vocal in promoting the extremes of Thatcherism even to the detriment of his own Party. As a Private Landlord, in 2014, Chope filibustered a Liberal Democrat bill, with cross party support, seeking to make revenge evictions an offence. Again, in 2015, he filibustered a private member’s bill seeking to restrict car parking charges on Carers at hospitals. His vision is resolutely Thatcherite: he steered the Poll Tax through Parliament; and, his chosen tool is the Private Members Bill. Which helped to ensure the Referendum on European Membership took place. What he does not like he talks into the ground.

Which all begs the question of why a Thatcherite former vice-chairman of the Tory Party would be presenting a bill for co-payment and co-funding since the NHS already operates a co-payment system. Indeed, why would a Member of Parliament waste time on something that already happens when there are so many other issues demanding attention. Across Europe there are a variety of ways in which Healthcare is funded. All involve some degree of co-payment.

1. No co-payments: The Netherlands and Malta.

2. Flat-rate co-payments: Austria, Italy.

3. Implied ceiling flat rate co-payment (prepayment certificate): UK.

4. Percentage rates co-payment: Belgium, France, Greece, Estonia, Latvia, Lithuania, Poland, Portugal, Slovakia, Slovenia and Spain.

5. Percentage rate co-payment with annual ceiling: Finland.

6. Uniform percentage co-payment: Cyprus, Germany, Norway.

7. Co-insurance, with percentage decreasing with accumulated expenditure over a given period and with a ceiling: Denmark and Sweden.

8. Deductible co-payment: Ireland, Sweden.

9. Many countries have explicit exemptions for certain products, as well as for some patient and socio-economic groups.

The only places with zero co-payments are the Netherlands and Malta. Co-payment is the usual European model. Co-payment intrinsically limits the amount paid and allows for exemption. Even in Belgium, France, and so on, the percentage co-payment is open to reduction by negotiation, prepayment or even poverty. Importantly, co-payment takes place at the point of delivery. There is always a way to avoid the refusal of treatment with co-payment. The Economists explanation of co-payment is that it provides an entry cost into the Healthcare Market for the Healthcare recipient which avoids moral hazard. Moral hazard occurs when someone increases their exposure to risk when insured because they are insured. It is the accusation placed against the Banks in 2007. When there were claims Banks were ‘too big to fail’, the claims of moral hazard disappeared. Moral hazard only applies if you are, economically, small, according to policy makers. Fundamentally, co-payments across Europe have been about ensuring equity that is fairness not avoiding moral hazard.

Co-payment as a mechanism for ensuring fairness have always been viewed with suspicion by health economists because co-payment leads to value based pricing of healthcare. Value Based Pricing is distinct from Cost Based Pricing in placing a price onto goods or services based on the value to the purchaser not the cost to the provider. Cost Based Pricing determines how much the time and materials a service or goods cost, a profit margin is applied and the buyer charged.

Buyers of Cost Based Pricing products can always push prices down towards cost. The slogan Think like a patient, act like a taxpayer is being repeated, mantra-like, by close friend of Boris Johnson and former president of United Health Group Inc. – an American commercial health company – as the head of NHS England. It is intended to justify the moving of 36 treatments out of the NHS into a purely co-funded basis. Unlike co-payment, co-funding is never waived. Co-funding ensures that there is a fundamental shift in the relationship between Doctor and Patient.

Since 1948, the NHS has operated on the basis that a Doctor makes a decision about the treatment for a Patient and the Patient receives that treatment from the NHS. The decision involves no third parties. Under a co-funding healthcare model – the decisions about the value of the therapy are made by the Third Party Payee. That Third Party Payee both determines the pricing and the availability based on assessments of value. The Third Party explicitly shapes prescribing decisions through various guidelines and incentives. This is the general system that operates in the US where people think like a patient and act like a premium payer – because the tax paid is a premium paid to an Insurer. The difference between the experience of Florence Nightingale and Mary Seacole is the difference between co-payment and co-funding.

Florence Nightingale could decide on any treatment she wished to give to the Troops. When she did so, she could appeal to sponsors and donors to pay for those treatments. Mary Seacole recommended the treatments that she was experienced with which were particularly around communicable diseases such as cholera. Unless she could find an approving donor, she was obliged to pay out of her own funds. Lack of social connections and her acceptance of the need for Soldiers to have a social existence kept donations at a distance.

Both Nightingale and Seacole were operating on a cost based pricing model and the outcome for both were, economically, different. Both Nightingale and Seacole were accepting payments from those they treated but Seacole would waive fees for those who could not pay or if it served the health of others around that person for them to be treated. She was forced into co-funding of treatments because failing to treat cholera simply because someone cannot pay promotes the spread of cholera. It was that utilitarian compassion that made Seacole a national hero. It was also the success of her approach – that of broadly socialised medicine – that helped to galvanise the Far Right of the Conservative Party into demanding Seacole was removed from the national curriculum and to rabid opposition to her statue being erected as a memorial on NHS Property.

Legitimately, there are those who point out that the Tories are racists who have a problem with Black People from the Caribbean in the Health Service. That point is hugely important but ignores that Seacole was obliged to be a completely commercial healthcare provider which bankrupted her. The fundamental problem was not simplistically racism but that private healthcare simply fails to work. Which illustrates the kind of smokescreen that the Tories adopt: nudging people into an argument about one thing when the real issue is elsewhere: talk about racism and lose the NHS or talk about the NHS and suffer racism.

There is no mistake in saying that the Cosmopolitan nature of British society outside Whitehall and the Establishment is what created the NHS, and that Mary Seacole was an important step along the path to the 1948 Act; but, that distracts from what the National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve.

Mary Seacole illustrated what happens when co-payment and co-funding coexist: someone goes bust. Co-payments are limited and, despite being almost universal in their enforcement, can be waived. Poor people should not die because they are not poor. Introducing co-funding ends the capacity to waive a co-payment. Co-payment is a gateway to full co-funding. Co-payment establishes a threshold price and the result is a shift from Cost Based Pricing to Value Based Pricing. Healthcare co-payment, connected to co-funding, nudges policy from Cost Based Healthcare to Value Based Healthcare by claiming that a Value Based Price should be “largely consistent with the values and preferences of the vast majority of the insured population”.

Value Based Pricing sets a prices according to the value of a product or service to the Payer rather than according to the cost of the product to the Seller. There needs to be no connection to cost based prices or even historical prices. The aim is simply to increase profitability without a need to increase sales volumes. Which is essential in commercial healthcare where successful treatment reduces the need for treatment and failed treatment removes customers from the market.

Value Based Pricing principally works in to the benefit of the Seller. It relies on the perceptions of the Buyer which leads right back to Nudge Theory. For Value Based Pricing the single most valuable emotion is not desire but fear. Realistically, it is Fear Based Pricing that relies on the Buyer being in fear of not obtaining the product. Co-payments create low level fear yet co-funding not only creates low level fear in the short term but reinforces that fear in the longer term. Which creates the environment for perpetual nudge. Value Based Pricing leads to such things as Surge Pricing as operated by Gig Economy Apps such as Uber. Surge Pricing raises price when there is higher demand because there is higher fear of not being able to obtain the service. For the Health Service that kind of Surge Pricing would be apparent around “flu season” or communicable disease outbreaks.

Value Based Pricing is not only about maximising profit but also acknowledge to be associated with high levels of fraud. Co-funding creates a purely Value Based Pricing market place, meaning that co-payments are, at best, a loss leader. With the current Co-payment system in place, it would be possible for a Pharmacist to look at a prescription and tell the Patient that a cheaper over the counter alternative exists. The same would be possible with a General Practitioner: it would be possible for a General Practitioner to recommend a box of generic paracetamol at twenty pence instead of a prescription at three pounds eighty.

Under a system where Co-funding and Co-payment are both present, it is normal for both General Practitioners and Pharmacists to be contractually unable to give any pricing advice whatsoever. Indeed, the American Medical Association, found that 28% of prescriptions for generic drugs included an element of overpayment and 6% of branded drugs included an element of overpayment. The prescription has become, for a good many Americans a nudge into purchasing. The General Practitioners and Pharmacists have terms and conditions dictated by a third party: which is the outcome of marketplace healthcare.

Overpayment at the point of dispensing is counted as healthcare fraud. The FBI estimates that Health Care Fraud costs American tax payers $80Bn/y. Of this amount $2.5Bn was recovered through the False Claims Act in the Financial year 2009-2010 at the cost of paying out $0.3Bn to whistle-blowers. Prescription fraud is not the only source of fraud. Wherever there is a mixture of co-payment and co-funding, there is an elevated level of fraud. This includes Billing for services not rendered, overcharging services and items through computer coding, duplicate charges for items, unbundling treatment packages and charging for individual items, excessive and unnecessary services as well as bribes and falsified medical records.

In fact, where there is fraud in any Healthcare System there is a reduction in life expectancy for Healthcare users. This is particularly evident where medical records are falsified for any reason. The single biggest source of fraudulent activity is around Third Parties being involved in the Patient-Doctor relationship.

The annual cost of Fit To Work assessments, in general, was expected to rise to £579m in 2016-17, it did so. Part of that rise was due to Atos walking away from a contract as Third Party to the Doctor Patient relationship for sick and disabled people. Each employment and support allowance (ESA) test had a price hike from £115 to £190 in order to continue doing them. This was hailed as being contracting out of public services when, in fact, it was the invention of a whole new service, already carried out by General Practitioners, in order to create a Third Party to the relationship between Doctors and Patients. The track record of that relationship has been abysmal – the majority of decisions based on the Third Party are overturned by an appeals process. The important thing is not to be distracted by the large, growing, literature and documentation of rising death rates, suicides and failed decisions but to focus on the entire Work Capability Assessment (WCA) being a government contract with Key Performance Indicators (KPI) that drive organisational behaviours.

By walking away from the contract, Atos demonstrated that the DWP were locked into a Value Based Pricing contract and so the 65% price hike from £115 to £190 is perfectly understandable. The simple reason that the Government paid up was that the assessment price was a co-funding arrangement.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out to achieve the institutionalisation of co-payment and co-funding into the NHS. Currently Co-payment exists but there is no lever to be pulled that can nudge Patients into behaving as Consumers. In articles about the frequency and magnitude of co-payments exceeding prescription costs, there is frequently expressed the concern that Consumers are prevented from knowing the full nature of the relationship between themselves and the Third Party. For example, Pharmacists and General Practitioners can be placed into a non disclosure relationship with the Third Party where they cannot be told of a better and cheaper treatment. Because the Third Party manages the relationship between Doctor and Patient. Surveys among US Independent Pharmacies indicate that, despite denials, this is common practice. Which makes perfect sense in an economy that is being pushed into Value Based Pricing even if it is reprehensible behaviour.

The promotion of Value Based Pricing into UK Healthcare is not simply about making a profit. It also seeks to promote behaviour change. To change the behaviour of all NHS Patients into being NHS Customers. Without institutionalised co-funding and co-payment as paired policies, turning Patients into Customers becomes an uphill struggle. Christopher Chope navigated the Poll Tax through the Commons, changing a property based taxation into a person based taxation. It turned out badly, yet neither he nor his opposition dwell upon the fundamental change of relationship between Electorate and Local Authorities that it created. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 has a far bigger impact.

Martin Shkreli, infamous for hiking the price of Tiopronin (trade name Thiola) from $1.30 to $30, caused outrage demonstrates the power of Value Based Pricing. In 2015, in Shkreli’s company acquired Daraprim: an out of patent drug with no generic version available. The price of a dose of the drug in the U.S. market increased from US$13.50 to US$750 per pill. In interviews, Shkreli explained that co-payments would be lower for patients as the new owner of the drug ensured many patients would get the drug at no cost, through a free drug program, and that it sold half of its drugs for one dollar. Which were all technically correct statements.

What they actually revealed was how dysfunctional co-payment becomes in the presence of co-funding. Co-funding introduces the Third Party to the Doctor Patient relationship. Which is already understood to be dysfunctional from the outcomes at the DWP. Importantly co-funding introduces a Choice Architecture into healthcare which makes future healthcare subject to the Libertarian Paternalism of Nudge.

Value Based Pricing is generally acknowledged to lack intellectual honesty. In reality it is a matter of charging what you can get away with not what the product or service costs. Organisations who deliver a product on a Value Based Pricing basis often push Cost Based Pricing onto their supply chain resulting in inflation of profits. In a commercial environment this is poor treatment but in a Healthcare environment it unsustainable poor treatment that kills the customer base as well as the supplier base.

Combined with co-funding, it locks new market entrants out and so ends the possibility of the NHS reducing costs. In that sense, locking co-payment and co-funding together is little more than an invitation to fraud. While Value Based Pricing is controlled by, for example, the National Institute Of Clinical Excellence (NICE), the advocacy is in favour of the Electorate. NICE might well make unpopular decisions but the are decisions that are rational and internationally respected. Passing Value Based Pricing decisions to a Third Party – as happened at the DWP – changes the advocacy to be for the owners of the treatment.

The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 sets out in a deceptively simple amendment to Section 1 followed by an equally simple looking amendment to section 12E of the National Health Service Act 2006. The overall impact is to change the relationship between the NHS and the Patient:

the making and recovery of charges is expressly provided for by or under any enactment, whenever passed”

Allows the Government to introduce charging by Statutory Instrument. A process that takes a week or so. This would allow for charges to be put in places for any treatment, drug, appliance or activity of the NHS by placing a document with the preamble: “In exercise of the powers conferred on me by The National Health Service (Co-funding and Co-Payment) Bill 2018, I hereby make the following Order:” At which point any charge can be placed into effect. The Statutory Instrument simply needs to remain unchallenged for 40 days and it becomes Law. The last occasion that the House of Commons annulled a Statutory Instrument was in 1979. So, whenever a Statutory Instrument is passed into law, NHS Charges to the Patient could be changed. Which simply means that all that is required is an active Lobbying Group and any NHS Tariff could be amended or even new ones created.

Which is not simply about nudging people to eat less sugar or cease smoking. It is about nudging Legislators to slavishly implement Value Based Pricing decisions of a wide range of goods, products, services, treatments and activities of the NHS. While this seems localised to the UK, the truth is the pricing of Drugs and Treatments in the NHS affects purchasing decisions in 40% of the World’s Health Services. Value Based Pricing in a global market is easier if your product is being sold at a premium in an influential local market. The creation of an institutional nudge has immense, global, commercial value. Lobbying in the UK would avoid scrutiny in, for example, the US but the outcome would be the same: Value Based Prices could rise in America. By nudging Legislator rather than end Customer, the cost of nudging is significantly reduced and the impact is far greater. Not only is the nudge guaranteed to work but it has the force of law to prevent it being dismantled.

The NHS has one of the price drug regimes in the World. Co-payment already exists and needs no legislation to be introduced: it is as simple as asking a General Practitioner to prescribe and asking the price. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is not about kite flying or testing the waters or increasing choice for patients but about ensuring that Lobbyists are the Third Party getting between Doctors and Patients not only in the UK but right across the World.

What The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 will promise is more choice and better, cheaper care. The experience in the US where co-payment and co-funding is in place is that Health Tourism increases – people find it cheaper to travel to Canada to get a prescription filled – and fraud rises; but, much more importantly, Healthcare ceases to be about health and becomes a significant way for Third Party Investors to manage social behaviour. The biggest Nudge possible: locking everybody into your marketing plans.

In the same way as Martin Shkreli could claim a price rise was a price fall on the basis of complex Value Based Pricing calculations that are commercial secrets, The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 makes commercial secrets obligatory through Statutory Instruments, which not only ensures the NHS is privatised but that the Privatised NHS promotes healthcare cost rises across the planet.

It has been suggested that The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 should be filibustered into oblivion. That would not end the drive toward Privatisation. It would also not prevent the Bill from being presented again in a similar but different form. This is the experience of the Poll Tax: it was never popular but it was navigated towards legislation by careful use of procedure. Similarly the progress of the European Referendum was navigated by the careful use of Private Members’ Bills. The National Health Service (Co-funding and Co-Payment) Bill 2017-2019 is simply another example of the well tried technique of Thatcherite MPs. This time it embeds nudge into a central Institution of Society: the NHS. The Bill should be utterly repudiated and, along with it, the underlying presumption that the entire population can be nudged and deceived and their health manipulated for profit.

Article by Hubert Huzzah

Picture: Statue of Mary Seacole (Grounds of Saint Thomas’s Hospital London). Martin Jennings 2016.

 

Related

Private bill to introduce further charges to patients for healthcare services is due for second reading today

 


 

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From the abstract to the concrete: urban design as a mechanism of behaviour change and social exclusion

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I rarely venture into large retail areas and shopping centres. They make me feel unwell. I’m rather claustrophobic to begin with. I also have lupus, one of my symptoms is a quite extreme photosensitivity. The lighting in these places quite often triggers an attack of vertigo, nausea, incapacitating disorientation, co-ordination difficulties, muscle rigidity, temporary and severe visual distortions and a very severe headache.

However, I visited one recently with a friend, who was doing some last-minute Christmas shopping. He promised we would visit just two shops, and that our visit would be over quickly.

What struck me straight away is how much retail design is now just about revenue-producing. Shopping malls are unforgiving, soulless and unfriendly places. I was reminded of something I read by David Harvey, about the stark reality of shrinking, privatised and devalued public spaces. Neoliberal marketisation has manifested ongoing conflicts over public access to public space, where profiteering reigns supreme.

My experience of a shopping mall was deeply alienating and physically damaging. It brought with it a recognition of how some groups of people are being coerced and physically situated in the world – how citizens think and act is increasingly being determined by ‘choice architecture’ –  which is all-pervasive: it’s situated at a political, economic, cultural, social and material level. Hostile architecture – in all of its forms – is both a historic and contemporary leitmotif of hegemony. 

Architecture, in both the abstract and the concrete, has become a mechanism of asymmetrically changing citizens’ perceptions, senses, choices and behaviours – ultimately it is being used as a means of defining and targeting politically defined others, enforcing social exclusion and imposing an extremely authoritarian regime of social control. 

Citizens targeted by a range of ‘choice architecture’ as a means of fulfiling a neoliberal ‘behavioural change’ agenda (aimed at fulfiling politically defined neoliberal ‘outcomes’) are those who are already profoundly disempowered and, not by coincidence, among the poorest social groups. The phrase choice architecture implies a range of offered options, with the most ‘optimal’ (defined as being in our ‘best interest’) highlighted or being ‘incentivised’ in some way. However, increasingly, choice architecture is being used to limit the choices of those who already experience heavy socioeconomic and political constraints on their available decision-making options. 

The shopping mall made me ill very quickly. Within minutes the repulsive lighting triggered an attack of vertigo, nausea, co-ordination and visual difficulties. I looked for somewhere to sit, only to find that the seating was not designed for actually sitting on. 

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The public seating that’s just a prop.

This radically limited my choices. In order to sit down to recover sufficiently to escape the building, the only option I had was to buy a drink in a cafe, where the seating is rather more comfortable and fulfils its function. I needed to sit down in order to muster myself to head for the exit, situated at the other end of the building. 

At this point it dawned on me that the hostile seating also fulfils its function. In my short visit, I had been ushered through the frightfully cold, clinical and unfriendly building, compelled to make a purchase I didn’t actually want and then pretty much rudely ejected from the building. It wasn’t a public space designed for me. Or for the heavily pregnant woman who also needed to sit for a while. It didn’t accommodate human diversity. It didn’t extend a welcome or comfort to all of its guests. The functions and comforts of the building are arranged to be steeply stratified, reflecting the conditions of our social reality. The only shred of comfort it offered me was conditional on making a purchase.

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When the purpose of public seating isn’t taking the weight off your feet and providing rest.

Urbanomics and the cutting edge of social exclusion: what is ‘defensive architecture’ defending?

Social exclusion exists on multiple levels. The distribution of wealth and power, access to citizenship rights and freedoms, political influence and consideration are a few expressions of inclusion or exclusion. It also exists and operates in time and space – in places. 

Our towns and cities have also increasingly become spaces that communicate to us who ‘belongs’ and who isn’t welcome. From gated communities and the rise of private policing, surveillance and security to retail spaces designed to fulfil pure profiteering over human need, our urban spaces have become extremely anticommunal; they are now places where an exclusive social-spatial order is being defined and enforced. That order reflects and contains the social-economic order.

Retail spaces are places of increasing psychological and sensual manipulation and control. Hostile architecture is designed and installed to protect the private interests of the wealthy, propertied class in upmarket residential areas and to protect the private profiteering interests of the corporate sector in retail complexes.

The very design of our contemporary cities reflects, directs and amplifies political and social prejudices, discrimination and hostility toward marginalised social groups. Hostile architectural forms prevent people from seeking refuge and comfort in public spaces. Places that once reflected human coexistence are being encroached upon, restrictions are placed on access and limits to its commercial usage, demarcating public and private property and permitting an unrestrained commodification of urban spaces and property.

In 2014, widespread public outrage arose when a luxury London apartment building installed anti-homeless spikes to prevent people from sleeping in an alcove near the front door. The spikes, which were later removed following the public outcry, drew public attention to the broader urban phenomenon of hostile architecture.

Anti-homeless spikes in London

Dehumanising ‘defensive architecture’ – ranging from benches in parks and bus stations that you can’t actually sit on, to railings that look like the inside of iron maidens, to metal spikes that shriek ‘this is our private space, go away’ – is transforming urban landscapes into a brutal battleground for the haves and socioeconomically excluded have-nots. The buildings and spaces are designed to convey often subtle messages about who is welcome and who is not.

Hostile architecture is a form of urban design that aims to prevent people from lingering in public spaces. The anti-homeless spikes here, for example, were installed to deter beggars and those sleeping rough.

Hostile architecture is designed and installed to target, frustrate deter and ultimately exclude citizens who fall within ‘unwanted’ demographics.

Although many hostile architecture designs target homeless people, there are also a number of exclusion strategies aimed at deterring congregating young people, many of these are less physical or obvious than impossibly uncomfortable seating, which is primarily designed and installed to prevent homeless people from finding a space to sleep or rest. However, the seating also excludes others who may need to rest more frequently, from sitting comfortably – from pregnant women, nursing mothers with babies and young children to those who are ill, elderly and disabled citizens.

Some businesses play classical music as a deterrent – based on an assumption that young people don’t like it. Other sound-based strategies include the use of high-frequency sonic buzz generators (the ‘mosquito device’meant to be audible only to young people under the age of 25.

Some housing estates in the UK have also installed pink lighting, aimed at highlighting teenage blemishes, and deterring young males, who, it is assumed, regard pink ‘calming’ light as ‘uncool’. There is little data to show how well these remarkably oppressive strategies actually work. Nor is anyone monitoring the potential harm they may cause to people’s health and wellbeing. Furthermore, no-one seems to care about the psychological impact such oppressive strategies have on the targeted demographics –  the intended and unintended consequences for the sighted populations, and those who aren’t being targeted.

                   Blue lighting in public toilets via Unpleasant Design

Blue lighting has been used in public toilets to deter intravenous drug users; the colour allegedly makes it harder for people to locate their veins. It was claimed that public street crime declined in Glasgow, Scotland following the installation of blue street lights, but it’s difficult to attribute this effect to the new lighting. Blue may have calming effects or may simply (in contrast to yellow) create an unusual atmosphere in which people are uncomfortable – actingout or otherwise. So questions remain about causality versus correlation. Again, no-one is monitoring the potential harm that such coercive strategies may cause. Blue light is particularly dangerous for some migraine sufferers and those with immune-related illnesses, for example, and others who are sensitive to flickering light. 

Hostile architecture isn’t a recent phenomenon

Charles Pierre Baudelaire wrote a lot about the transformation of Paris in the 1850s and 1860s. For example, The Eyes of the Poor captures a whole series of themes and social conflicts that accompanied the radical re-design of Paris under Georges-Eugène Haussmann‘s controversial programme of urban planning interventions.

Baron Haussmann was considered an arrogant, autocratic vandal by many, regarded as a sinister man who ripped the historic heart out of Paris, driving his boulevards through the city’s slums to help the French army crush popular uprisings. Republican opponents criticised the brutality of the work. They saw his avenues as imperialist tools to neuter fermenting civil unrest in working-class areas, allowing troops to be rapidly deployed to quell revolt. Haussmann was also accused of social engineering by destroying the economically mixed areas where rich and poor rubbed shoulders, instead creating distinct wealthy arrondissements.

Baudelaire opens the prose by asking his lover if she understands why it is that he suddenly hates her. Throughout the whole day, he says, they had shared their thoughts and feelings in the utmost intimacy, almost as if they were one. And then:

“That evening, feeling a little tired, you wanted to sit down in front of a new cafe forming the corner of a new boulevard still littered with rubbish but that already displayed proudly its unfinished splendors. The cafe was dazzling. Even the gas burned with all the ardor of a debut, and lighted with all its might the blinding whiteness of the walls, the expanse of mirrors, the gold cornices and moldings…..nymphs and goddesses bearing on their heads piles of fruits, pates and game…..all history and all mythology pandering to gluttony.

On the street directly in front of us, a worthy man of about forty, with tired face and greying beard, was standing holding a small boy by the hand and carrying on his arm another little thing, still too weak to walk. He was playing nurse-maid, taking the children for an evening stroll. They were in rags. The three faces were extraordinarily serious, and those six eyes stared fixedly at the new cafe with admiration, equal in degree but differing in kind according to their ages.

The eyes of the father said: “How beautiful it is! How beautiful it is! All the gold of the poor world must have found its way onto those walls.”

The eyes of the little boy: “How beautiful it is! How beautiful it is! But it is a house where only people who are not like us can go.”

As for the baby, he was much too fascinated to express anything but joy – utterly stupid and profound. 

Song writers say that pleasure ennobles the soul and softens the heart. The song was right that evening as far as I was concerned. Not only was I touched by this family of eyes, but I was even a little ashamed of our glasses and decanters, too big for our thirst. I turned my eyes to look into yours, dear love, to read my thoughts in them; and as I plunged my eyes into your eyes, so beautiful and so curiously soft, into those green eyes, home of Caprice and governed by the Moon, you said:

“Those people are insufferable with their great saucer eyes. Can’t you tell the proprietor
to send them away?”

So you see how difficult it is to understand one another, my dear angel, how incommunicable thought is, even between two people in love.”

I like David Harvey‘s observations on this piece. He says “What is so remarkable about this prose poem is not only the way in which it depicts the contested character of public space and the inherent porosity of the boundary between the public and the private (the latter even including a lover’s thoughts provoking a lover’s quarrel), but how it generates a sense of space where ambiguities of proprietorship, of aesthetics, of social relations (class and gender in particular) and the political economy of everyday life collide.”  

The parallels here are concerning the right to occupy a public space, which is contested by the author’s lover who wants someone to assert proprietorship over it and control its uses.

The cafe is not exactly a private space either; it is a space within which a selective public is allowed for commercial and consumption purposes.

There is no safe space – the unrelenting message of hostile architecture

What message do hostile architectural features send out to those they target? Young people are being intentionally excluded from their own communities, for example, leaving them with significantly fewer safe spaces to meet and socialise. At the same time, youth provision has been radically reduced under the Conservative neoliberal austerity programme – youth services were cut by at least £387m from April 2010 to 2016. I know from my own experience as a youth and community worker that there is a positive correlation between inclusive, co-designed, needs-led youth work interventions and significantly lower levels of antisocial behaviour. The message to young people from society is that they don’t belong in public spaces and communities. Young people nowadays should be neither seen nor heard.

It seems that the creation of hostile environments – operating simultaneously at a physical, behavioural, cognitive, emotional, psychological and subliminal level – is being used to replace public services – traditional support mechanisms and provisions – in order to cut public spending and pander to the neoliberal ideal of austerity and ‘rolling back the state’. 

It also serves to normalise prejudice, discrimination and exclusion that is political- in its origin. Neoliberalism fosters prejudice, discrimination and it seems it is incompatible with basic humanism, human rights, inclusion and democracy.

The government are no longer investing in more appropriate, sustainable and humane responses to the social problems created by ideologically-driven decision-making, anti-public policies and subsequently arising structural inequalities – the direct result of a totalising neoliberal socioeconomic organisation.

For example, homeless people and increasingly disenfranchised and alienated young people would benefit from the traditional provision of shelters, safe spaces, support and public services. Instead both groups are being driven from the formerly safe urban enclaves they inhabited into socioeconomic wastelands and exclaves – places of exile that hide them from public visibility and place further distance between them and wider society. 

Homelessness, poverty, inequality, disempowerment and alienation continue but those affected are being exiled to publicly invisible spaces so that these processes do not disturb the activities and comfort of urban consumers or offend the sensibilities of the corporate sector and property owners. After all, nothing is more important that profit. Least of all human need.

Homelessness as political, economic and public exile

Last year, when interviewed by the national homelessness charity Crisis, rough sleepers reported being brutally hosed with water by security guards to make them move on, and an increase in the use of other ‘deterrent’ measures. More than 450 people were surveyed in homelessness services across England and Wales. 6 in 10 reported an increase over the past year in ‘defensive architecture’ to keep homeless people away, making sitting or lying down impossible – including hostile spikes and railings, curved or segregated, deliberately uncomfortable benches and gated doorways.

Others said they had experienced deliberate ‘noise pollution’, such as loud music or recorded birdsong and traffic sounds, making it hard or impossible to sleep. Almost two-thirds of respondents said there had been an increase in the number of wardens and security guards in public spaces, who were regularly moving people on in the middle of the night, sometimes by washing down spaces where people were attempting to rest or sleep. Others reported noise being played over loudspeakers in tunnels and outside buildings.

Crisis chief executive Jon Sparkes said he had been shocked by the findings. He said: “It’s dehumanising people. If people have chosen the safest, driest spot they can find, your moving them along is making life more dangerous. 

“The rise of hostile measures is a sad indictment of how we treat the most vulnerable in our society. Having to sleep rough is devastating enough, and we need to acknowledge that homelessness is rising and work together to end it. We should be helping people off the streets to rebuild their lives – not just hurting them or throwing water on them.”

‘Defensive architecture’ is a violent gesture and a symbol of a profound social and cultural unkindness. It is considered, calculated, designed, approved, funded and installed with the intention to dehumanise and to communicate exclusion. It reveals how a corporate oligarchy has prioritised a hardened, superficial style and profit motive over human need, diversity, complexity and inclusion. 

Hostile architecture is covert in its capacity to exclude – designed so that those deemed ‘legitimate’ users of urban public space may enjoy a seemingly open, comfortable and inclusive urban environment, uninterrupted by the sight of the casualities of the same socioeconomic system that they derive benefit from. Superficially, dysfunctional benches and spikes appear as an ‘arty’ type of urban design. Visible surveillance technologies make people feel safe.

It’s not a society that everyone experiences in the same way, nor one which everyone feels comfortable and safe in, however.

Hidden from public view, dismissed from political consideration

Earlier this month, Britain’s statistics watchdog said it is considering an investigation into comments made by Theresa May following complaints that they misrepresented the extent of homelessness and misled parliament.

The UK Statistics Authority (UKSA) confirmed that concerns had been raised after the prime minister tried to claim in Parliament that ‘statutory homelessness peaked under the Labour government and is down by over 50 per cent since then.’ Official figures show that the number of households in temporary accommodation stood at 79,190 at the end of September, up 65% on the low of 48,010 in December 2010. Liberal Democrat peer Olly Grender, who made the complaint, also raised concerns last year about the government’s use of the same statistics.

Grender said: “It seems particularly worrying, as we learn today of the increase in homelessness, that this government is still using spin rather than understanding and solving the problem.”

Baroness Grender’s previous complaint prompted UKSA to rebuke the Department for Communities and Local Government. The department claimed homelessness had halved since 2003 but glossed over the fact this referred only to those who met the narrow definition of statutory homelessness, while the overall number of homeless people had not dropped. 

May was accused of callousness when Labour MP Rosena Allin-Khan recently raised questions about homelessness and the rise in food bank use. The prime minister responded, saying that families who qualified as homeless had the right to be found a bed for the night. She said: “Anybody hearing that will assume that what that means is that 2,500 children will be sleeping on our streets. It does not.

“It is important that we are clear about this for all those who hear these questions because, as we all know, families with children who are accepted as homeless will be provided with accommodation.”

Finger wagging authoritarian Theresa May tells us that children in temporary accommodation are not waking up on the streets.

However, Matthew Downie, the director of policy at the Crisis charity for homeless people, said: “The issue we’ve got at the moment is that it’s just taking such a long time for people who are accepted as homeless to get into proper, stable, decent accommodation. And that’s because local councils are struggling so much to access that accommodation in the overheated, broken housing market we’ve got, and with housing benefit rates being nowhere near the market rents that they need to pay.”

He said that while May highlighted a decline in what is categorised as ‘statutory homelessness’, rough sleeping had increased by 130% since 2010.

The category of ‘statutory homelssness’ has also been redefined to include fewer people who qualify for housing support.

Last year, May surprisingly unveiled a £40 million package designed to ‘prevent’ homelessness by intervening to help individuals and families before they end up on the streets. It was claimed that the ‘shift’ in government policy will move the focus away from dealing with the consequences of homelessness and place prevention ‘at the heart’ of the government’s approach. 

Writing in the Big Issue magazine – sold by homeless people – May said: “We know there is no single cause of homelessness and those at risk can often suffer from complex issues such as domestic abuse, addiction, mental health issues or redundancy.”

However, there are a few causes that the prime minister seems to have overlooked, amid the Conservative ritualistic chanting about ‘personal responsibility’ and a ‘culture of entitlement’, which always reflects assumptions and prejudices about the causal factors of social and economic problems. It’s politically expedient to blame the victims and not the perpetrators, these days. It’s also another symptom of failing neoliberal policies.

It’s a curious fact that wealthy people also experience ‘complex issues’ such as addiction, mental health problems and domestic abuse, but they don’t tend to experience homelessness and poverty as a result. The government seems to have completely overlooked the correlation between rising inequality and austerity, and increasing poverty and homelessness – which are direct consequences of political decision-making. Furthermore, a deregulated private sector has meant that rising rents have made tenancies increasingly precarious.

Last year, ludicrously, the Government backed new law to prevent people made homeless through government policy from becoming homeless. The aim is to ‘support’ people by ‘behavioural change’ policies, rather than by supporting people in material hardship – absolute poverty – who are unable to meet their basic survival needs because of the government’s regressive attitude and traditional prejudices about the causes of poverty and the impact of austerity cuts.

Welfare ‘reforms’, such as the increased and extended use of sanctions, the bedroom tax, council tax reduction, benefit caps and the cuts implemented by stealth through Universal Credit have all contributed to a significant rise in repossession actions by social landlords in a trend expected to continue to rise as arrears increase and temporary financial support shrinks.

Housing benefit cuts have played a large part in many cases of homelessness caused by landlords ending a private rental tenancy, and made it harder for those who lost their home to be rehoused.

The most recent National Audit Office (NAO) report on homelessness says, in summary:

  •  88,410 homeless households applied for homelessness assistance
    during 2016-17 
  • 105,240 households were threatened with homelessness and helped to remain in their own home by local authorities during 2016-17 (increase of 63%
    since 2009-10) 
  • 4,134 rough sleepers counted and estimated on a single night in autumn
    2016 (increase of 134% since autumn 2010)
  • Threefold approximate increase in the number of households recorded
    as homeless following the end of an assured shorthold tenancy
    since 2010-11
  • 21,950 households were placed in temporary accommodation outside the local
    authority that recorded them as homeless at March 2017 (increase
    of 248% since March 2011)
  • The end of an assured shorthold tenancy is the defining characteristic of the increase in homelessness that has occurred since 2010

Among the recommendations the NAO report authors make is this one: The government, led by the Department [for Housing] and the Department for Work and Pensions, should develop a much better understanding of the interactions between local housing markets and welfare reform in order to evaluate fully the causes of homelessness.

Record high numbers of families are becoming homeless after being evicted by private landlords and finding themselves unable to afford a suitable alternative place to live, government figures from last year have also shown. Not that empirical evidence seems to matter to the Government, who prefer a purely ideological approach to policy, rather than an evidence-based one. 

The NAO point out that Conservative ministers have not evaluated the effect of their own welfare ‘reforms’  (a euphemism for cuts) on homelessness, nor the effect of own initiatives in this area. Although local councils are required to have a homelessness strategy, it isn’t monitored. There is no published cross-government strategy to deal with homelessness whatsoever. 

Ministers have no basic understanding on the causes or costs of rising homelessness, and have shown no inclination to grasp how the problem has been fuelled in part by housing benefit cuts, the NAO says. It concludes that the government’s attempts to address homelessness since 2011 have failed to deliver value for money.

More than 4,000 people were sleeping rough in 2016, according to the report, an increase of 134% since 2010. There were 77,000 households – including 120,000 children – housed in temporary accommodation in March 2017, up from 49,000 in 2011 and costing £845m a year in housing benefit. 

Homelessness has grown most sharply among households renting privately who struggle to afford to live in expensive areas such as London and the south-east, the NAO found. Private rents in the capital have risen by 24% since the start of the decade, while average earnings have increased by just 3%.

Cuts to local housing allowance (LHA) – a benefit intended to help tenants meet the cost of private rents – have also contributed to the crisis, the report says. LHA support has fallen behind rent levels in many areas, forcing tenants to cover an average rent shortfall of £50 a week in London and £26 a week elsewhere.  This is at the same time that the cost of living has been rising more generally, while both in-work and out-of-work welfare support has been cut. It no longer provides sufficient safety net support to meet people’s basic needs for fuel, food and shelter. 

It was assumed when welfare amounts were originally calculated that people would not be expected to pay rates/council tax and rent. However, this is no longer the case. People are now expected to use money that is allocated for food and fuel to pay a shortfall in housing support, and meet the additional costs of council tax, bedroom tax and so on. 

Local authority attempts to manage the homelessness crisis have been considerably constrained by a shrinking stock of affordable council and housing association homes, coupled with a lack of affordable new properties. London councils have been reduced to offering increasingly reluctant landlords £4,000 to persuade them to offer a tenancy to homeless families on benefits.

Housing shortages in high-rent areas mean that a third of homeless households are placed in temporary housing outside of their home borough, the NAO said. This damages community and family ties, disrupts support networks, isolates families and disrupts children and you people’s education.

London councils are buying up homes in cheaper boroughs outside of the capital to house homeless families, in turn exacerbating the housing crisis in those areas. 

Polly Neate, the chief executive of the housing charity Shelter, said: “The NAO has found what Shelter sees every day, that for many families our housing market is a daily nightmare of rising costs and falling benefits which is leading to nothing less than a national crisis.”

Matt Downie, the director of policy and external affairs at Crisis, said: “The NAO demonstrates that while some parts of government are actively driving the problem, other parts are left to pick up the pieces, causing misery for thousands more people as they slip into homelessness.”

Meg Hillier MP, the chair of the Commons public accounts committee, said the NAO had highlighted a ‘national scandal’. “This reports illustrates the very real human cost of the government’s failure to ensure people have access to affordable housing,” she added. 

More than 9,000 people are sleeping rough on the streets and more than 78,000 households, including 120,000 children, are homeless and living in temporary accommodation, often of a poor standard, according to the Commons public accounts committee.

The Committee say in a report that the attitude of the Department for Communities and Local Government (DCLG) to reducing homelessness has been ‘unacceptably complacent’.

John Healey, the shadow housing secretary, said: “This damning cross-party report shows that the Conservatives have caused the crisis of rapidly rising homelessness but have no plan to fix it.

“This Christmas the increase in homelessness is visible in almost every town and city in the country, but today’s report confirms ministers lack both an understanding of the problem and any urgency in finding solutions.

“After an unprecedented decline in homelessness under Labour, Conservative policy decisions are directly responsible for rising homelessness. You can’t help the homeless without the homes, and ministers have driven new social rented homes to the lowest level on record.”

Surely it’s a reasonable and fundamental expectation of citizens that a government in a democratic, civilised and wealthy society ensures that the population can meet their basic survival needs. 

The fact that absolute poverty and destitution exist in a wealthy, developed and democratic nation is shamefully offensive. However, Conservatives tend to be outraged by poor people themselves, rather than by their own political choices and the design of socioeconomic processes that created inequality and poverty. The government’s response to the adverse consequences of neoliberalism is increasingly despotic and authoritarian.

The comments below from Simon Dudley, the Conservative Leader of the Maidenhead Riverside Council and ironically, a director of a Government agency that supports house building, (Homes and Community Agency (HCA)) reflect a fairly standardised, authoritarian, dehumanising Conservative attitude towards homelessness.

Note the stigmatising language use – likening homelessness and poverty to disease – an epidemic. Dudley’s underpinning prejudice is very evident in the comment that homelessness is a commercial lifestyle choice, and the demand that the police ‘deal’ with it highlights his knee-jerk authoritarian response:

Dudley uses the word ‘vagrancy’, which implies that it is the condition and characteristics of homeless people who causes homelessness, rather than social, political and economic conditions, such as inequality, low wages, austerity and punitive welfare policies. The first major vagrancy law was passed in 1349 to increase the national workforce and impose social control following the Black Death, by making ‘idleness’ (unemployment) and moving to other areas for higher wages an offence. The establishment has a long tradition of punishing those who are, for whatever reason, economically ‘inactive’: who aren’t contributing to the private wealth accumulation of others.

The Vagrancy Act of 1824 is an Act of Parliament that made it an offence to sleep rough or beg. Anyone in England and Wales found to be homeless or begging subsistence money can be arrested. Though amended several times, certain sections of the original 1824 Vagrancy Act remain in force in England and Wales. It’s main aim was removing undesirables from public view. The act assumed that homelessness was due to idleness and therefore deliberate, and made it a criminal offence to engage in behaviours associated with extreme poverty. 

The language that Dudley uses speaks volumes about his prejudiced and regressive view of homelessness and poverty. And his scorn for democracy.

The 1977 Housing (Homeless Persons) Act restricted the homeless housing requirements so that only individuals who were affected by natural disasters could receive housing accommodation from the local authorities. This was partly due to well-organised opposition from district councils and Conservative MPs, who managed to amend
the Bill considerably in its passage through Parliament, resulting in the rejection of many  homeless applications received by the local government because of strict qualifying criteria.

For the first time, the 1977 Act gave local authorities the legal duty to house homeless people in ‘priority’ need, and to provide advice and assistance to those who did not qualify as having a priority need. However, the Act also made it difficult for homeless individuals without children to receive accommodations provided by local authorities, by reducing the categories and definitions of ‘priority need’. 

Use of the law that criminalises homeless people may generally include:

  • Restricting the public areas in which sitting or sleeping are allowed.
  • Removing the homeless from particular areas.
  • Prohibiting begging.
  • Selective enforcement of laws.

Murphy James, manager of the Windsor Homeless Project, branded Cllr Dudley’s comments ‘disgusting’ and described the Southall accommodation offered by the Royal Borough of Windsor & Maidenhead as ‘rat infested’. 

He said: “It shows he hasn’t got a clue. He has quite obviously never walked even an inch in their shoes.

“It is absolutely disgusting he is putting out such an opinion that it is a commercial life choice.”

James added the royal wedding should not be the only reason for helping people on the streets.

“I am a royalist but it should have zero to do with the royal wedding,” he said.

“Nobody in this country should be on the streets.” 

Dudley should pay more attention to national trends instead of attempting to blame homeless people for the consequences of government policies, as many in work are also experiencing destitution.

This short film challenges the stereoytypes that Dudley presents. This is 21st century Britain. But still there are people without homes, still people living rough on the streets, including some who are in work, even some doing vital jobs in the public sector, low paid and increasingly struggling to keep a roof over their heads. Central government doesn’t keep statistics on the ‘working homeless’. But we do know that overall the number of homeless people is once again on the rise.

Meanwhile, figures obtained via a Freedom of Information request by the Liberal Democrats from 234 councils show almost 45,000 people aged 18-24 have come forward in past year for help with homelessness. With more than 100 local authorities not providing information, the real statistic could well be above 70,000.

As Polly Toynbee says: “Food banks and rough sleeping are now the public face of this Tory era, that will end as changing public attitudes show rising concern at so much deliberately induced destitution.”

While the inglorious powers that be spout meaningless, incoherent and reactionary authoritarian bile, citizens are dying as a direct consequence of meaningless, incoherent and reactionary Conservative policies.

 


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