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Working Paper WG 2 – Transformation of Welfare

Working Paper WG 2 – Transformation of Welfare

Historical and Contemporary Perspectives on the Transformations of Welfare in Europe

Steven D. Brown (Nottingham Trent University), Kateřina Králová (Charles University), Marileen La Haije (Universität zu Köln), Isabel Machado Alexandre (Instituto Universitário de Lisboa)

 
 
Introduction

The post-World War II reconstruction from 1945 onwards brought with it a massive transformation in the ways in which states organized welfare and healthcare systems. In Portugal, the public healthcare system, the Serviço Nacional de Saúde (SNS), was founded in 1979, providing comprehensive healthcare services to the country’s residents. Across Scandinavia, the Nordicmodel established a universal welfare state, albeit one which enshrined an historical ‘compromise’ between capital and labour. In those countries which were subsumed under the USSR sphere of influence, there was the readjustment to the colossal outreach of state managed bureaucracy in all aspects of welfare. While in the UK, this took the form of the creation of the National Health Service (NHS), which united practically all forms of health services into a single, overarching infrastructure, in Soviet Union and countries of Eastern and Central Europe all health services were financed from a tax-filling budge within direct responsibility of the communist governments as a single payer.

This initial grand transformation, which in many cases can be precisely dated (e.g. the creation of the NHS on 5th July 1948),drew on longstanding political and economic debates, given sudden impetus by the closing of the second world war. It initiated a period of some three decades or more during which many of the welfare arrangements that defined modern European states were refined and progressively embedded. For instance, the idea that universal healthcare could absorb all aspects of wellbeing, including mental health, drug addiction counselling and elderly care, and could in turn be integrated within population level lifespan planning, became a taken-for-granted aspect of social policy in many European nations. But this ‘compact’ around welfare has not lasted – the welfare systems which now operate acrossEurope have been subject to a gradual reconfiguration that has in many cases resulted in an undoing of post-war social and economic settlements.

Some of these more recent transformations can also be dated. For instance, the neoliberal measures taken by successivegovernments throughout Europe (such as UK, the Netherlands, Nordic countries) since the 1980s and 1990s has created ahighly marketized and outsourced welfare. At the same time, the dissolution of the USSR and the accession of manycentral European states to the European Union has resulted in a no less dramatic reshaping of welfare systems. But thenature, speed and timing of these transformations is much more difficult to discern and thus to memorialise andcommemorate. There is – as yet – no clear consensus on exactly when the Nordic model became more heavily marketized, on when the very idea of the NHS came to be called into question. Nevertheless, something profound has happened tothe universal model of ‘cradle-to-grave’ care provided by the state and complex new forms of exclusion and division have become enacted. There is an urgent need to address how these changes can become objects of remembering, and how to foster communities of memory who find themselves at the sharp end of neoliberal social and economic violence.

In order to address this, we will need to explore how the idea of slow memory can become attuned to the subterranean currents of gradual and uneven transformations of social welfare systems. In some case, these transformations have begun from suchdifferent starting points that the post-war social compact never really properly existed in the first place. To paraphrase Bruno Latour, in welfare terms some communities ‘have never been modern’ to begin with. Equally, there are significant social groups, such as mental-health service users, who have been under-served all along, merely in different ways during the post-war and post-1980s periods. Some of these transformations also have a somewhat non-linear character, where echoes and recapitulations of prior historical practices are repeated at different scales. For example, the nineteenth century workhouse no longer exists at any density across Europe, but decentralized and informally managed practices associated with modern slavery(e.g. captive housing, indentured labour, massive personal debt) are found everywhere, not least suffered by migrant workers.

As an opening attempt in developing our thinking, we make three scholarly moves. First, we schematically note a number of ways in which the post-war compact impacted on the lived experiences of recipients of welfare and the consequences this hadfor collective and personal remembering. Second, we extend this towards the current welfare landscape in an effort to make a broad comparison and to establish the memorial challenges this currently creates. Finally, and substantively, we propose aseries of analytic domains that might prove fruitful for further development in understanding the purchase slow memory has on changing welfare arrangements in and beyond Europe.

The Welfare Compact

The history of welfare systems is dominated by the rise (and fall) of institutions. Whether it be the grand asylums in which those deemed mentally unwell were incarcerated from the seventeenth century onwards, to the children’s homes and workhouses that dominate the nineteenth century model of addressing poverty, the carceral large institutions were the cornerstone of welfare prior to universal services. Institutions of this kind tended to be geographically and socially isolated from the wider communities around them. Asylums, for instance, were often places outside of urban settings on sites where there was the ability to conduct small-scale farming and manage separate water supplies. This enclosure meant that the communities which existed within institutional settings were separated off from the histories and commemorative practices of the nearby populations.

Michel Foucault memorably described the institutional system around social welfare and education as a ‘penal archipelago’.The prison, with restrictive spaces, dense regulations and individualising practices of inmates, became both the discursive code and material arrangement around which other institutions were fashioned. Following this logic, hospitals start to look like schools, which come to resemble workhouses, and all ultimately arrive at the model of the prison. But whilst this story captures something of the misery of confinement and the disciplining of subjectivity, it fails to recognise some of the differences between institutional settings. For instance, a relationship to nature is one of the defining features of nineteenth century asylums(because of its supposed ‘restorative’ qualities), whereas the ‘warehousing’ of bodies in a space designed to be both punitive and productive defines prisons or workhouses at this time.

Institutional care is also far more interdependent and diffuse in terms of its overall organization than Foucault’s analysis would suggest. For example, the first Magdalene Laundries in Ireland were known as ‘asylums’ but became vehicles for promoting a particular version of strict moral order, with a quasi-juridical role in supposedly reducing prostitution (there is no evidence that this was effective). Over time, the laundries became engines of profit and also more closely integrated into the prison-industrialsystem. Classically, asylums themselves have always performed a role in the state policing of poverty, with some nineteenth century asylums dividing into separate ‘pauper’ and ‘middle-class’ facilities. Whilst this blurring of functions within the overall welfare system suggests a kind of fluidity between exactly where persons might enter into the system itself, transition into and out of institutional setting is by definition difficult. The idea of becoming ‘lost’ within the system is fundamental to the way these institutions operate and provides an uncanny echo of the later notion of cradle-to-grave care.

As Goffman would later describe some of the remaining large asylum spaces that existed in the 1950s, entry into and exit from institutional spaces tends to follow a common pattern. Inmates undergo a ritual stripping away of their prior identity, a dehumanising process which is designed to reconstruct the person on the basis of a narrow number of characteristics defined by the institution itself. Goffman acutely describes this process as a ‘moral career’ in which personal transformation, albeit of a limited kind, is forcibly enacted. The resulting identity which the person gains is stigmatized, in the double sense that it is typically an unwanted or discredited identity, and one which becomes permanently marked. In this sense, to enter into an institutional space is to become perpetually linked to that institution and also a ‘carrier’ of the qualities that define that spacewho takes them back into the community on release.

However, in comparison with more recent institutional settings, nineteenth century institutions, especially asylums, maintained quite exhaustive records of lives of inmates during their time in care. A mental health service user entering into inpatient care in the UK will be required to participate in an information gathering exercise known as ‘formulation’, where they will discuss their own recent history in order to inform care-planning. But in early nineteenth century asylums, clinicians and other staff would take fulsome notes of conversations with patients and descriptions of their concerns, moods and behaviours. In part this was because prior to the introduction of a common, standardised diagnostic system, there was no other way of deliveringcare without becoming aware of the specific circumstances of the patient. There are echoes here of what has now returned as ‘personalisation’ within healthcare settings throughout Europe (although this remains underdeveloped within mental health care). Diagnosis nevertheless renders such information less important because it triages patients onto pre-defined treatment pathways.

This level of record-keeping offers considerable resources for establishing biographies and other memory work carries out by (former) inmates of institutions. But records tended to be kept within individual institutions rather than being circulated at thelevel of the welfare system, as would happen, for instance, in the care of looked-after children in the contemporary system. In this sense, memory is tied to the institution itself and, in this way, unable to travel with the person as they move outside and beyond. Moreover, the record keeping practices of traditional institutional care are not really ‘interoperable’. Each institutional practice maintained its own specialist language which was only strictly relevant to its functions. Again, there is a point of divergence with Foucault’s analysis here, which treats prisons, for instance, as the ways in which the state comes to ‘know’ inmates and thus classify and manage the broader populations from which they are drawn. Children’s homes or workhouses might have been engines for the governance of poverty, but they did not do so by ‘remembering’ the persons who passed through them in any way that was consequential beyond the time when they were institutionalized.

The most significant aspect of the post-war welfare compact in Europe is its logic of redistributing different mechanisms for the delivery of welfare across a range of institutional settings and developing bureaucratic processes for conveying information between those settings. For example, the role of the ‘health visitor’ within the UK healthcare system made it possible to gradually reduce the length of hospital stay around childbirth, whilst still maintaining surveillance over the welfare of newborn children. This is only possible through a whole system of standardized information gathering around birth weight, physical and mental development, patterns of ‘good parenting’, etc. that is co-ordinated through General Practice surgeries. The welfare compact is then the creation of a system that can speak some forms of common language. It is also a system that remembers persons at multiple points and seeks to curate biographical information over time.

The complexity of the system perhaps inevitably means that state co-ordination and intervention is required. That in turn means that for most citizens, there is no ‘outside’ to the welfare system since it requires considerable effort to go ‘off grid’ and not engage with or become ‘known to’ state agencies at multiple points. This is not to say that the system maintains continuous, complete and/or perfect knowledge. Within the increased complexity of the system there is also new forms of specialism (e.g. community mental health crisis teams) and more points of potential failure and in/miscommunication. The idea of vulnerable persons – particularly children, including unaccompanied child asylum seekers – becoming ‘lost’ to the systemrather than lost within the system (as was the case with institutional care) is one of the major concerns of late twentieth century welfare in Europe. It is the distributed memorial capacity of the system as a whole rather than institutional memory at the individual level that becomes criticaI.

Neoliberal transformations

It is commonplace but often not terribly informative to categorise all of the colossal changes that have occurred around welfare from the 1980s onwards as driven by ‘neoliberalism’.

However, the profound role of marketization and financialization as the twin processes most often associated with neoliberal reform are critical to any account of this period. Welfare systems across Europe have made far greater use of out-sourced providers as states gradually withdrew from some aspects of universal care whilst increasing regulatory oversight. For example,in the UK, the Netherlands and, to some extent, also in former Eastern Bloc countries there has been a significant expansion inthe role of private providers at all levels in education, coupled with a continuous reformulation of the government and non-governmental bodies which have been put in place to maintain oversight.

Clearly there are significant differences across Europe in terms of the speed and depth of marketization, but the general direction of travel appears to be the same. Underpinning this is the increased reliance on financialization, either through private insurance, public pensions or complex financial instruments put in place to ensure that public funding delivers ‘best value’. Thistends to render the citizen as the manager of a portfolio of resources designed to support their welfare across the lifespan,rather than as the object of cradle-to-grave care by the state. For example, in the Dutch welfare system a portion of elderly care is provided by local municipalities which calculate a ‘personal budget’ for older citizens. In the UK, patients are able to ‘jump the queue’ for medical care through using private medical insurance, which will typically be provided by NHS doctors doingadditional private work at separate commercial facilities. The same applies to public and private health services, which are paid directly without necessarily accepting the health insurance, in Greece, Czechia, Slovakia and elsewhere in Central East and Southeast Europe.

Increased privatization of services has also strengthened the drive towards de­ institutionalization. The traditional abolitionist argument for closing down carceral institutions, including psychiatric hospitals, is broadly rights-based. But in a marketized system the dominant argument is that it is simply too expensive to maintain such institutions. The rough cost of a day in inpatient care in mental health services in the UK is

£350 (or £127,750 per year, with many patients staying between four to eighteen months). A ‘care contact’ with a communitymental health team member is £118, and a consultation with an outsourced private counsellor paid for by the NHS is £105. The trajectory since the 1980s has then been a significant reduction in the number of inpatient beds, the closure of larger institutional psychiatric spaces in favour of smaller units and more community-based teams and greater reliance on the private sector to handle ‘complex needs’. The former institutions are typically sold on cheaply to private developers who then convert the space into luxury apartments.

The closure of institutional spaces has a direct impact on memory. Given the importance of space as one locus which facilitates remembering, erasing the traces of former institutional sites can unpick the histories of the persons who moved through thosespaces. For example, the eating disorders unit at St. Anne’s hospital in Haringey (UK) was surrounded with walls into whichpatients had carved their initials and dates of stay for many decades. These walls were destroyed in the refurbished unit which opened in 2020, leaving no trace of this material history. The current unit, like all modern mental health units, has no spaces in which

patients might ‘write themselves into’ the fabric of the space. It is a temporary space that patients pass through whichretains none of their past when they are gone. Damian O’Doherty has observed that if historically institutions resembledone another in a ‘penal archipelago’, as Foucault observed, then the discursive and material code of modern welfare settings is the airport departure lounge (an archetypal ‘non-space’ without memory).

Patterns of migration also intersect in complex ways with de-institutionalization. The response of many European nations to migration driven by conflict (and climate change) has been to resort to carceral strategies – effectively re-institutionalization.But at the same time, migrants can also become lost within welfare systems, either deliberately as a means of managing immigration status, or through apparent neglect by the state. In 2023, there were approximately 200 unaccompanied child asylum seekers ‘missing’ from state provided hotel care in the UK, presumably at risk of trafficking or exploitation. The logic of ‘knowing’ citizens through interoperable welfare knowledge then appears to have various points of exclusion and failure. At thesame time, there is apparently little concern for preserving the memories and histories of migrants who become displaced or who, tragically, die during the course of their perilous journeys into Europe. This strongly contrasts with the manner in which more established migrant communities have been able to develop their own memorial infrastructure over time and place.

Something, then, is happening to the very fabric of the way that welfare is provided, governed, experienced and engaged withacross Europe. Whilst we can say that this ‘something’ is strongly related to changing political and economic conditions, we are not able to properly locate just what has changed – what has been lost, what has been transformed – because of the tendency of welfare to lose memory within the system itself. And this inability to adequately remember and reflect on these transformations is seriously undermining the capacity to imagine anything different in the future.

Five Ds

To begin to counter this, we offer a heuristic series of five loose analytic domains (alliteratively organized forconvenience). These are not intended as comprehensive or even as particularly systematic, but merely marking out somepotential lines of thought.

Dispersal

Europe is marked by significant patterns of migration, both within the borders of the Schengen area, and from beyond, with displacement from the conflicts in Syria and Afghanistan (amongst others) and those in Northern Africa, coupled with climate change. It might be said that the very idea of Europe cannot be thought outside of continuous migration, in the same way that modern European nation states have their origins in migrations and diasporas dating from the first millennium. But the currentforms of dispersion represent a significant shift in the way that migrants pass between different welfare systems and are passed between different agencies within national welfare systems.

For example, the systems rapidly put in place by national governments across Europe to accommodate migrants from the Ukraine conflict oftentimes provided only a minimal infrastructure and resource base in which ‘hosts’ could contact migrants.The systems that have emerged in the UK and elsewhere, have more in common with the technologies typically associatedwith dating apps than it does with a co-ordinated project of caring for persons fleeing conflict. This has exposed migrants topotential exploitation as well as shifting moral and financial responsibility from the state to individual citizens. The potential formigrants to become willingly or unwillingly lost in such a dispersed welfare arrangement is enormous.

We might then ask how the dispersion of persons – often with significant risks and vulnerabilities – intersects with welfare systems that are increasing distributed, dependent on voluntary or at least non-state actors, and which seem to have apparently minimal regulation. How do persons travelling across Europe either voluntarily or involuntarily become lost within(or to) these systems? What happens to their stories and lived experiences? Whose responsibility is it to hear, record and remember them?

Dislocation

The closure of the institutional sites has typically resulted in an erasure of memory. The majority of memory work at these sites was resourced by either local record keeping systems, the ongoing presence of communities of memory (e.g. former staff and inmates who remained attached to the site) or through material traces at the site itself. Whilst some institutions do have a recognisable afterlife, as either a museum or heritage site (e.g., the Museum of the Mind in Haarlem, the Netherlands, is situated in a formed asylum), or remain within the same system (e.g. the Springfield psychiatric hospital in Greater Manchester, which was originally a workhouse, then an asylum and has been recently demolished to be replaced with a new-build mental health unit), others become erased entirely. Sometimes this is because of the economics of developing prime real estate or because the site has maintained an ambivalent historical relationship with the local community (such as Severalls Hospitalin Colchester, UK). But in this latter case there is a genuine problem of where memory goes when it is no longer able toseek the support of the places to which it relates.

The lack of place specific-markers, and, moreover, the lack of desire to commemorate what can sometimes be seen as a problematic aspect of the history of welfare provision, is challenging. The abolitionist discourse has at times been hijacked bypure economic rationalisation. Asylums were closed in part because they were too expensive rather than purely from a rights-based agenda. This makes it difficult to explore and reinterpret aspects of institutional care that actually might have value for the future. For example, the ways in which institutional spaces could be personalised by the communities of patients and staff is now mostly lost in the highly regulated and extremely risk-averse designs of modern mental health units, which are obsessed with removing ligature points and other potential sources of risk to self and others. Equally, the ability to grow foodor care for animals on which asylums depended, and which arguably provided some therapeutic benefit, is now increasinglywritten out of history. The erasure of institutional space can then foreclose on the ability to challenge current practices. We probably do not want to build a new generation of huge asylums (although that, perversely, is exactly what is happening insome units, particularly amongst non-NHS providers in the UK), but we do want to be able to remember and imagine something different to what we currently have.

Do we then need to develop a different relationship to these erased institutional spaces? Is there a way that might be done without challenging the current material arrangement of those spaces – perhaps through digital technologies such as digitaltwinning? What is the complex relationship between places and events? How do we entertain the ‘hauntings’ of conflicted institutional spaces within the present?

Degrowth

The myth of progress is surely at its most powerful in relation to changing welfare systems. The simple binary is often mobilised of the failure and shame of the past, when we did not know how to properly care for persons in distress, at risk, sufferingdisadvantage, set against the present, when we really are trying our best to get the balance between rights and risks, to place lived experience at the heart of welfare arrangements, to make sure that no-one is let down or left behind. Many communities of service-users would find this a rather hollow joke and argue instead that whilst the present may be different, exclusion and indifference remain the hallmarks of welfare systems. Things may not be quite going backwards, but they are certainly not improving in any straightforward sense. We may not lock the poor in workhouses anymore, but we remain relatively well-adjusted to the idea of homelessness, or cutting the benefits of the vulnerable and leaving them to die alone in unfit rental properties they can barely afford.

The degrowth movement has begun to shift our thinking on the narrative of progress, in relation to both economic growth and, ultimately, sustainability and climate change. But there is a stubborn point in all of this. Welfare is typically seen as something that can only really be properly supported when the economy is buoyant. If we no longer believe in economic growth, then how can we imagine improved welfare arrangements? Are we then thrown back towards a fuzzy notion that it will be theresponsibility of ‘the community’ to look after its own? Or ought we to desperately look for renewed forms of philanthropy from the current generation of tech-billionaires, some of whom appear to have little grasp of what a social conscience might feel like? Part of the problem is that of unpacking how welfare became so subordinated to a narrowly defined notion of social and economic reorganization that we are unable to entertain different notions of care and what they might look like outside of a purely economic evaluative framework. And that problem will become all the worse the more that ‘climate anxiety’ is replaced with the terrifying realitiesof living through global environmental change.

The relevant questions would then seem to be around how care has become entangled with economics and establishing what aspects of our histories provide us with other alternatives. As our vulnerabilities become increasingly intersectional (i.e. youth and economic exclusion and mental health and climate change), there is an urgent need for a different language around progress and welfare.

Digitisation

Measurement is central to the organization of welfare practices. Without population level statistics, it is difficult to identify and target specific needs. Without trend data, changes in patterns of vulnerability are rendered invisible. Without financializing outcomes in some way, it becomes impossible to argue for the merits of one intervention over another. But measurement remains in some sense antithetical to lived experience, the quantitative objectification of life against the rich qualitative feelings of life as it unfolds. Indicators and measures, especially those made possible by big data and Al, are central to currentdebates around welfare. How can we then participate in those debates without losing sense of the stories, voices and experiences that are taken hold of by those quantitative techniques? Is there such a thing as ‘good’ and ‘bad’ objectification?

The digitisation of welfare systems has often been presented as a liberatory project. But it has often ended in disaster. For example, the digitisation of patient records in the UK collapsed as both a technical and political project, undone by the technological and organizational complexity of what was needed and the widespread suspicion that personal data would beassetized and sold.

Digital technologies make the past tractable and memorable in ways that would have been previously difficult to imagine. But they do so through a transformation of experience that may render that past as something which was never really experienced as such at the time. The problem then seems to turn around a series of dualisms: How does the qualitative and the quantitative intersect in the ways in which welfare systems come to ‘know’ and ‘record’ experience? What happens when the materiality of heritage (e.g. record keeping, objects, places) is virtualised? Can you really balance care with finance and technology without turning a crucial aspect of something human either willingly or unwillingly into an asset?

Destigmatization

Another version of the progress argument is that we are just so much better now at embracing one another’s vulnerabilities.Everyone talks about mental health nowadays, so that those who life with distress shouldn’t feel so bad about it. We know that many children live at risk and in poverty and that’s why we try to donate to charities who want to do something about it. It’sawful when conflict destroys communities and homes and it’s only right that we welcome those who are the victims. The project of destigmitization seems to be progressing well across so many areas. And yet, one set of vulnerabilities is sometimes seized upon within populist politics to discredit another. Throughout Europe, the far right want to reverse migration in the name of defending children. Trans persons are restigmatized in arguments about supposed threats to womens’ rights. In de UK, mental health campaigns sanitize the idea that ‘its OK to not be OK’ but baulk at forms of distress that are challenging, confrontationalor messy. Once again, it’s not necessarily that things are going backwards, it’s more that there is continuous looping and de- and re- stigmatization occurring simultaneously.

Stigmatization involves the forced ownership of a discredited identity which reduces the complexity of subjectivity to a limited number of imagined qualities. But these identities are themselves complex bundles of descriptions and projected desires that are somewhat unstable. For example, the category of Attention-Deficit Hyperactivity Disorder (ADHD) has had a complex recent history. Originally invoked as a way to justify and manage classroom exclusion in what would previously have beendescribed as ‘naughty children’, ADHD has recently been reinvented as a description for the difficulties of managing short term digital media engagements with other activities. For many young adults this previously highly stigmatized term just ‘makes sense’ of particular difficult experiences they have around managing interactions and committing to activities, to the point where it is now the primary focus of much student welfare support in universities across and beyond Europe. We might well ask how this transformation occurred and what other terms within a shifting hierarchy of vulnerabilities have become displaced as a consequence.

The inability to tell non-linear stories of the way that vulnerabilities have intersected with welfare systems in complex ways is part of the problem. Why do particular groups become objects of concern, or worse, sources of risk and predation at specific moments? How do those vulnerabilities intersect and in what ways do those intersections pass through loops of (re)stigmatization? How do these transformations in the crediting and discrediting of identities occur and what kinds of autobiographical remembering and other memory work might they give way to?

Photo credits: Wikicommons

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