Richard Titmuss: Welfare and Society

Richard Titmuss Welfare and Society Second Edition

David Reisman

Richard Titmuss

Also by David Reisman ADAM SMITH’S SOCIOLOGICAL ECONOMICS ALFRED MARSHALL: Progress and Politics ALFRED MARSHALL’S MISSION ANTHONY CROSLAND: The Mixed Economy CONSERVATIVE CAPITALISM: The Social Economy CROSLAND’S FUTURE: Opportunity and Outcome THE ECONOMICS OF ALFRED MARSHALL GALBRAITH AND MARKET CAPITALISM MARKET AND HEALTH THE POLITICAL ECONOMY OF HEALTH CARE THE POLITICAL ECONOMY OF JAMES BUCHANAN STATE AND WELFARE: Tawney, Galbraith and Adam Smith THEORIES OF COLLECTIVE ACTION: Downs, Olson and Hirsch

Richard Titmuss Welfare and Society David Reisman

Second Edition

© David Reisman 1977, 2001 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First edition published 1977 by Heinemann Educational Books Second edition published 2001 by PALGRAVE Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N. Y. 10010 Companies and representatives throughout the world PALGRAVE is the new global academic imprint of St. Martin’s Press LLC Scholarly and Reference Division and Palgrave Publishers Ltd (formerly Macmillan Press Ltd). ISBN 0–333–80050–8 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Reisman, David A. Richard Titmuss : welfare and society / David Reisman.—2nd ed. p. cm. Includes bibliographical references and index. ISBN 0–333–80050–8 1. Social policy. 2. Public welfare. 3. Welfare state. 4. Titmuss, Richard Morris, 1907–1973. I. Title. HN16 .R44 2001 361.6’1—dc21 2001021633 10 10

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Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham, Wiltshire

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Contents Acknowledgements 1

vii

Introduction

1

PART ONE: The Status of Social Policy 2

The Definition of Social Policy

29

3

Some Methodological Considerations

43

4

Part One: Evaluations and Extensions

52

(a) The Sub-Division of Welfare (b) The Origins of Welfare

53 72

PART TWO: Selectivity 5

Stigma

91

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Part Two: Evaluations and Extensions

98

PART THREE: Universalism 7

Universalism I: Social Costs and Social Benefits

113

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Universalism II: Integration and Involvement

123

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Universalism III: Planned Redistribution

137

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Part Three: Evaluations and Extensions

158

(a) (b) (c) (d)

159 174 181 189

Externalities Blood Community Legitimation

PART FOUR: The Failure of the Market 11

The Failure of the Market I: Quality

203

12

The Failure of the Market II: Choice

217

13

The Failure of the Market III: Quantity

230

v

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Contents

14

The Failure of the Market IV: Price

237

15

Part Four: Evaluations and Extensions

241

(a) (b) (c) (d)

243 246 253 261

16

Scarcity Choice Growth Pattern Maintenance

Conclusion

269

(a) Social Science and Social Philosophy (b) The Importance of Social Theory

270 273

Abbreviations of Books by R.M. Titmuss

277

Notes

278

Index

300

Acknowledgements The author and publishers are grateful to Ann Oakley for permission to quote from the publications and unpublished papers of Richard Titmuss. They would also like to thank the staff of the Archives Section of the British Library of Political and Economic Science for their assistance.

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1 Introduction

Richard Morris Titmuss was appointed Professor of Social Administration at the London School of Economics in 1950. He was not the architect of the modern British social services state, but he soon made himself its ideologue, although as much its critic as its advocate. His impact on the intellectual underpinnings of welfare and society in the complacent and consensual Britain that came in with Attlee and Bevan and went out with the Thatcherites and the Monetarists simply cannot be underestimated. In the words of Ann Oakley: The post-war period was a brave new world to many. It was one with which Richard Titmuss was intimately associated. He influenced the manner in which the welfare state evolved and was understood, not only in Britain, but as a model to be emulated and improved on by other countries. The Labour Party in the 1950s, ’60s and ’70s, particularly its social security and pension plans, would not have been the same without him.1 Nor, as Robert Pinker states, would the academic discipline of social policy: ‘Few scholars have so dominated the development of an academic subject over so long a period . . . He was one of those rare thinkers who are able to shift the whole focus of debate in a field of study.’2 David Donnison, drawing the balance both of the socialism and of the scholarship, was right to return the following verdict at the time of Titmuss’s early death: ‘For years to come, political parties and governments in many parts of the world will find themselves using his ideas or responding to the prodding of his disciples.’3 That is also the verdict of the present book. 1

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Richard Titmuss

The Eleanor Rathbone Memorial Lecture of 1955 contained the manifesto. In ‘The Social Division of Welfare’ (published in 1956 and best known from the 1958 Essays) Titmuss sought to widen the discussion of social welfare by situating public services in cash and kind in the framework of a general matrix of privileges (not least fiscal and occupational welfare) and values (most of all, community, integration and equality). Brian Abel-Smith and Kay Titmuss called it ‘perhaps the most influential piece he ever wrote’.4 Pinker has this to say about the 1955 milestone and the work that was to come: ‘In his seminal essay, “The Social Division of Welfare”, Titmuss broke through the then conventional and narrow definitions of social policy . . . By focusing upon aims rather than administrative procedures, he brought a new analytical dimension to his subject.’5 It was an analytic that was to impart a remarkable consistency of outlook to the books and papers that he produced while a professor at the LSE. His main publications in the years in which his thinking solidified into his mature analytic were Essays on ‘The Welfare State’ (1958) (republished in 1963 to include a revised version of his 1959 Fabian Tract on The Irresponsible Society), Income Distribution and Social Change (1962), Commitment to Welfare (1968), The Gift Relationship (1970) and Social Policy (1974). The last-named is a posthumously published set of lecture notes, edited by Brian AbelSmith and Kay Titmuss, which he had used in the University of London. Titmuss was also the co-author of three influential studies of more specialised interest: The Cost of the National Health Service in England and Wales (1956) (with Brian Abel-Smith), Social Policies and Population Growth in Mauritius (1961) (with Brian Abel-Smith and Tony Lynes) and The Health Services of Tanganyika (1964) (with Brian Abel-Smith, George Macdonald, Arthur Williams and Christopher Ward). All of this was foreshadowed by his monumental Problems of Social Policy (1950) – his panoramic study of the human costs of war and the unified nationhood that the bombing, the evacuation and the homelessness had produced – that Pinker with good reason describes as ‘still his masterpiece’.6 Titmuss’s analytic reached its maturity in the LSE quarter-century of ‘you’ve never had it so good’, Keynesian full employment, partypolitical Butskellism and the National Health. His formative years, however, had been those of inter-war unemployment, the Jarrow marches, the exhaustion of benefits, the public-spending cuts of Sir Eric Geddes which in 1922 had put macroeconomics before ‘homes fit for heroes’, the Public Assistance administrators (replacing the

Introduction

3

Poor Law guardians in 1929) who regularly means-tested the hungry by asking them how they had found the money for a new coat. No one understands Titmuss who forgets the Depression or who fails to read the books and papers which, antedating the Problems of Social Policy by a decade and more, give a clear picture of a Toynbee-like quester driven by his conscience to harness empiricism in the service of compassion. Of particular importance are Poverty and Population (1938), Our Food Problem (1939) (with F. Le Gros Clark), Parents Revolt (1942) (with Kay Titmuss), Birth, Poverty and Wealth (1943) and Report on Luton (1945) (with F. Grundy). These early books are hardly the contributions that Hilary Rose had in mind when she refers to Titmuss as a ‘central figure’ in policy studies, a thinker ‘whose work was to dominate social policy until his premature death in 1973’.7 What these early books do reveal is, however, the inception of a lifetime search to combine Tawney-like moral passion with the careful scientific research which the Webbs had made the precondition for social reform. The Problems and ‘The Social Division’ were to herald the emergence of a more sophisticated analytic. Even so, the Titmuss of 1938 is recognisably the same Toynbee-like quester as the Titmuss of 1970. The continuity comes as no surprise – since there is little in Titmuss’s considerable body of work that is not, as Wilding points out, deeply embedded in his own moral values: ‘They are implicit in nearly all he wrote, and they remain remarkably constant and consistent.’8 Titmuss’s moral values prescribed the track and the direction. One consequence is an intellectual system which was built to last. Titmuss was a systemic thinker who, in Wilding’s words, sought to generalise from the particular and to apply the all-embracing: In all he wrote, Titmuss was concerned with direct and immediate social policy issues. At the same time, he was also concerned with fundamental questions – the nature of the good society, the nature of social obligation, and the nature of social policy. His concerns and his ideas ranged widely as he moved from the particular to the general and from the general to the particular.9 Wilding in 1995 was able to recognise the macrosocial frame of reference which unifies the body of Titmuss’s work. In 1976, interestingly, he himself had denied its existence: ‘Titmuss was not a theorist . . . He was suspicious of attempts to construct broad, general theories of social policy development or the roles and functions

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of social services.’10 Mishra implicitly makes the same point when he complains that the theorists of the middle ground have allowed themselves to become stranded in a morass of piecemealism, pragmatism and eclecticism which in effect leaves them without a compass or a map to release them from the tyranny of the reactive ad hoc: ‘It is indeed something of a paradox that over three decades of successful welfare statism has not produced a “Centrist” theory of the mixed system comparable to the analytical perspectives of the market liberals and the Marxists.’11 While a word like ‘comparable’ must inevitably open the door to debate, this much at least is beyond dispute: Richard Titmuss developed a valuable intellectual system and is well deserving of the credit that is due to a genuinely innovative mind. It is appreciation of a kind that he has not always received. Richard Titmuss was an original, creative and sensitive thinker whose work has not always won the understanding it deserves. Titmuss is a difficult author, partly because he was more likely to write essays than book-length monographs (even a major book like Commitment to Welfare turns out to be a collection of separate essays), partly because so many of his occasional papers were the response to invitations (often to speak at international conferences on topics chosen for him by the organisers), partly because he never saw the need to make his underlying system fully explicit (in the obvious sense that he never set out to write a textbook, coherent and comprehensive). Abel-Smith and Kay Titmuss conjecture that he might later have wanted to produce his magisterial synthesis on Principles: ‘Perhaps, if he had lived longer, he would have brought it together in a different way. But sadly he did not.’ 12 One purpose of the present book is to reconstruct the system, to reassemble the pieces of the puzzle; and thus to demonstrate that the Titmussian world-view is a unified whole made one by an ambitious attempt to restore the study of welfare to its proper place in the study of society. A second purpose of the present book is to evaluate the system and to note its essential paradox: Titmuss most stressed integration but left certain aspects of his own model incomplete and unintegrated. To some extent, however, such imprecision is bound to be the fate of all those who attempt a science of society. It was not only for himself that Titmuss was speaking when he confessed: ‘The more I try to understand the role of welfare and the human condition the more untidy it all becomes.’13

Introduction

5

Richard Titmuss was born on 16 October 1907, the son of a Bedfordshire small farmer. The farm, near Luton, was broken up under Lloyd George’s scheme for distributing land to soldiers returning from the World War; and in 1918 the family moved to London where Morris Titmuss (first using horses and then lorries) established a small haulage business. The bankruptcy of that business, a sense of personal failure, a resentful wife and a tendency to drink all contributed to his death in 1926, aged only 53. Richard left school in 1921 when he was 14. He attended a sixmonth course in bookkeeping at a local commercial college and then became an office-boy in Standard Telephones and Cables Ltd. After his father’s death he entered the County Fire Insurance Office as a clerk. The contact was made by his mother. Richard, the family breadwinner at the age of 19, came to understand at first hand the burden of dependency: not only did he find himself responsible for an older sister and a younger brother, there was also the problem of the ‘desolate, incapable widow’,14 ‘intensely impractical and nervous’,15 whom Ann Oakley describes with no evident warmth as ‘a fat, self-indulgent, hypochondriachal woman with cow-like brown eyes and limitless demands’.16 Maude Titmuss (née Farr) had married young, and into a less affluent farming family. She never fully reconciled herself to the fact that her husband was only a small farmer become an alcoholic bankrupt. The consequence was that she was both financially and emotionally dependent on her son from 1926 until her death (aged 89) in 1972, only one year before Richard’s own. The financial strain at least was slightly eased when she won a football pool after the Second World War. Within the insurance company, Titmuss rose rapidly to become a London Inspector in 1939 at the early age of 32. He learned about the dependent both as statistics and as case histories, and also acquired an insight into the way in which institutional investors deploy their funds. Moreover, when he finally left County Fire in 1942, he personally fell victim to the exercise of power without responsibility through the loss of 16 years of occupational pension rights. Meanwhile, Richard Titmuss met Kathleen (Kay) Miller in 1934 while on a fortnight’s rambling holiday in North Wales. Middleclass, the daughter of a south London cutlery salesman, she had had more formal education than Richard. Having done a secretarial course, she was able to type his letters and (although there is no evidence of research work as well) the manuscripts of his first four

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Richard Titmuss

books. When they met she was doing low-paid, untrained social work in London clubs for the unemployed. Distributing clothes and books, mending worn-out jackets, arranging breaks in the country, she was seeing for herself what life without work meant for men and their families. In the Preface to his first book Titmuss wrote as follows about the contribution his helpmate and discussion-partner had made to the development of his social and political awareness: ‘It is my wife, Kay – not only by her part in the publication of this book, but through her work among the unemployed and forgotten men and women of London – who has helped me to visualise the human significance, and often the human tragedy, hidden behind each fact.’ 17 Richard and Kay were married in 1937. He was 29 and she was 33. Both still lived at home. They had one daughter, Ann (Oakley), born in 1944. Later she was to be Professor of Sociology and Social Policy in the University of London, with a special interest in health, education and gender studies. Her books include The Sociology of Housework, Social Support and Motherhood and Housewife, but also novels like The Men’s Room and The Secret Lives of Eleanor Jenkinson. In Taking it like a Woman – ‘a sort of autobiography’18 – and Man and Wife: Richard and Kay Titmuss she has made a valuable contribution to the understanding of her remarkable parents. Ann Oakley, looking back, was struck by the fact that Kay at marriage withdrew from her work in the unemployment centres (the only real job she is known to have had) and to have made Richard’s career her life: ‘Kay and Richard Titmuss were . . . only one couple among many; millions of men were freed for full participation in the world outside the home through the unpaid services of women within it.’19 Throughout their long life together (Kay outlived Richard by 14 years, dying in 1987), Kay was a source of strength and understanding. As Margaret Gowing says in her British Academy essay on Titmuss: ‘He could support the great weight of work and maintain his inner calm because of his happiness at home with Kay. Looking after Richard was her life work.’20 Ann Oakley’s impression of Kay’s self-defined mission is a similar one: ‘Almost the whole of her energy and passion was brought to bear on the task of supporting the idea of her husband as a great man.’21 Acknowledging the intellectual stimulation that the relationship must have meant, the high-powered social circles (from Lord Horder and Tawney to the Archbishop of Canterbury), the garden parties at Buckingham Palace, Ann Oakley none the less expresses the opinion

Introduction

7

that the traditional division of labour left her mother at the end of the day with a certain sense of personal frustration: ‘The fact that he became her work was something she was proud of; but it didn’t give her the same satisfaction as the work she once had which was her own.’22 The rivalry with the neurotic and possessive Maude for Richard’s affections cannot have done much to lift her spirits: at one point she labelled a photograph of Maude in the family album ‘The Evil One’. Nor should it be forgotten that even a dependent woman can be resentful of a controlling husband. However happy the home, however great the love on both sides, the fact is that Richard could be controlling.

The Vancouver Sun in 1966 called Kay a Pied Piper for her husband. Kay herself had a private vision ‘that Richard was her discovery’.23 While there is bound to be some truth in the contention that Richard was ‘Kay-made’24 even as he was self-made – Kay was convinced (others were less confident) that they discussed everything together – it is important to remember that even in the 1930s Richard appears to have been more politically alert than was Kay. A letter from 1935 reveals that Kay had little respect for the political leaders of the time: ‘I thought that if they could have the Christian Gospel in the background as an ideal and work towards that ideal a number of the present difficulties in this country and in fact the world would be more easily solved.’25 Richard, on the other hand, was already convinced that the mixed economy and social reform – neither Marxian class consciousness and revolution nor libertarian laissez-faire and unemployment – were inevitable and that the lead had to be a political one. In that sense he would have been in broad agreement with the two great classics of moderate interventionism that were published while he was at County Fire: Keynes’s General Theory (1936) and Macmillan’s Middle Way (1938). The intellectual high ground seemed to be the preserve of the reforming Liberals. Richard Titmuss joined the Hendon Young Liberals as early as 1932 – welcoming him, the Honorary Secretary observed that ‘liberals are few and far between in Hendon’26 – and was obviously not excessively discouraged by the fact that there had not been a Liberal Government for many years. He also began to attend the Fleet Street Parliament, a debating society meeting every Monday evening at St Bride’s Institute to obtain practice in public speaking. He was critical of County Fire, once calling it

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Richard Titmuss

‘Inefficiency Limited’.27 He did not hesitate to put his powers of persuasion to good use by campaigning bravely for higher salaries for the County staff. Before Kay as well as after Kay, in other words, Titmuss was looking to leadership and to argumentation for the impulse that would bring into being the Good Society. To that extent the Fabianism was there from the start. So long as Shaw was being photographed with Gorky and the Webbs were writing of Soviet Communism: A New Civilisation, it is clear that Titmuss, social reformer but not economic planner, could not have contemplated a closer association. Publication had to be the next step. In 1936 Titmuss wrote Crime and Tragedy. Its subject was errors in British foreign policy since the Treaty of Versailles; rearmament in Germany and the possibility of war; Hitler’s aggressiveness and the scope for the League of Nations. Because of his position in County Fire, Titmuss used the pseudonym Richard Caston. Kay supplied the pseudonym (Caston, her mother’s maiden name, was her middle name) and an unspecified amount of typing, correcting and rewriting. She need not have bothered. The manuscript was never published. The tone was judged polemical and the author was unknown. Then, however, came Poverty and Population and with it the attention of reformers and statisticians around the world.

Titmuss joined the Eugenics Society in 1937. He was still a member at the time of his death. Most of the contacts which were instrumental in getting his early writings into print or in securing him his posts in the Cabinet Office and later at the LSE were made through his involvement in the Eugenics Society. Titmuss published in (and, in the early 1940s, edited) its journal, the Eugenics Review. He was active in the war in selecting eugenically promising children for evacuation to Canada. He served on the Council of the Society. Francis Galton, cousin of Charles Darwin, had been the first to coin the term eugenics. Studying twins, he found that they remained similar in character even when separated in space. This led him in 1883 to declare that ‘nature prevails enormously over nurture’,28 and that there was little that a change in environment could do. The subject of genetic inheritance (and of selective breeding to upgrade the qualities of the stock) was widely debated in the 1930s. Not least was it debated because of Hitler’s policies on race, and because of British doctors’ curiosity to discover how far mental illness

Introduction

9

was an intergenerational gift. Eugenics in the 1930s was a mainstream topic in socio-political debate. Senior figures in national life were drawn to the Society and Titmuss had a chance to meet them. Personal impressions were important as Titmuss, largely self-educated, had no paper qualifications. Poverty and Population, Titmuss’s first published book, was his contribution to the debate on the who and the which of selection and survival. It was published in 1938 by Macmillan (Harold Macmillan, MP for Stockton-on-Tees, taking a personal interest in anything that could alleviate the absolute deprivation he saw in his constituency) and came with a Preface written by the physician to the Royal Family (Lord Horder, then President of the Eugenics Society: David Glass appears to have interested him in the project). Its subtitle was ‘A Factual Study of Contemporary Social Waste’. By factual, Titmuss meant that he was proposing to rely on statistics, both national and disaggregated. By waste, Titmuss meant that he could document the annual loss of 50 000 British lives that could otherwise have been spared. Titmuss’s book was published at a time when unemployment had hovered around the 2 million mark for almost 20 years – ‘and there is every indication that heavy unemployment is now a permanent feature of our civilisation’.29 In spite of that surplus Titmuss made clear that the 50 000 remained a cause for concern. One reason was the widespread fear in the 1930s that the British population was not only declining but declining too fast. A typical statement would be that of Beveridge in 1937: ‘In twenty-five years we shall be in a panic about the population of this country . . . The centre of the social sciences is going to be the problem of population.’30 A further reason was the possibility of war. In 1936 the rejection rate for military service in the Home Counties was 32 per cent; for England and Wales as a whole it was 48 per cent.31 This not only meant fewer recruits but also, as Titmuss writes, a selective bias in favour of the fitter south: ‘War is always dysgenic; that means to say it always kills the best types from amongst the biologically important age groups.’32 The population total was moving from surplus into deficit. Up to a half of Britain’s would-be soldiers were unfit for service. A future war would take a discriminatory toll of Britain’s best-quality breeders. Considerations such as these led Titmuss to document carefully the differentials in preventable illness and premature death as a preliminary to making recommendations that would protect the human stock.

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Richard Titmuss

Titmuss in his book is approaching the human stock from the perspective of innate potential. What he is saying, however, is that in certain circumstances nurture is the key that unlocks the hidden potential and empowers it to reach the level that nature made possible. The relationship between nutrition and intelligence is a case in point: ‘Many a child classed as dull or backward should have been recorded as deficient in vitamin A . . . There are substantial reasons for thinking that dietetically balanced meals increase mental output.’33 Environment cannot do what the endowment rules out – in that he is at one with Galton. Changes in conditions, on the other hand, can at least allow that which is already in successfully to get out: ‘Satisfactory diet allows valuable hereditary qualities to assert themselves.’34 Satisfactory diet allows it. Malnutrition and deprivation stunt it. Thus it was that Titmuss, specifically addressing the need to make the most of a genetically bounded scarce resource, began to put forward social reforms that would allow the nation to exploit limited ability to the full. Gifted children cannot make full use of educational opportunities if their drinking-water is polluted and their sustenance impoverished – but an answer is to be found in school milk and meals (including breakfast), medical services to contain infection and an improvement in the housing stock. In 1928–34 the maternal death-rate in the five principal coal-mining counties was 41 per cent higher, the infantile death-rate 51 per cent higher, than that prevailing in Middlesex and Essex35 – but the surplus in deaths could be significantly reduced if measures could be taken to break the vicious circle that linked low wages and high unemployment to family poverty and thence to disease, defect and underperformance. In all of this the proximate subject is diphtheria and tuberculosis, overcrowded slums and inadequate ventilation, but the real cause is lack of money. Poverty is the principal problem facing the poor. All those who believed with Galton in the upgrading of the race should turn to social reform for a meaningful answer to the inequality of outcomes handed on intergenerationally through fertility and reproduction. The poor breed more. That in itself is a sound enough reason for an economical nation to make the poor less poor over time.

Titmuss’s second book, Our Food Problem (written with F. Le Gros Clark and published in 1939), continued the discussion of

Introduction

11

malnutrition and stratification. It proved both influential and controversial: some 30 000 copies were sold as a Penguin Special before the outbreak of war. The book is in two parts. The first, ‘Britain’s Food Supplies in War’, was written entirely by Clark. It dealt with the minutiae of storage, blockade, rationing, state trading in food and the optimal siting of stocks. The second, entitled ‘Stamina of the British People’, was a collaborative effort of the two authors. It began by stating the obvious, that in war as in peace Britain had need of a ‘lively and vigorous population’,36 energetic and purposeful. It then evoked the sociological evidence Titmuss had previously collected on economic deprivation and preventable mortality to demonstrate that poverty was a threat to physical stamina – and inequality a threat to ‘social stamina’ which is the cause and effect of equity and sharing: When folk like the British . . . cease to believe that society is organically constructed to serve the common good of all, they begin from that moment to lose their morale . . . There is a sickness of the soul as well as of the body; and if we are to persuade our people to fight for their world, it must be a world that is patently providing them with the first essentials of life . . . If there is one thing few men can stomach to-day, it is the growing divergence of interests between rich and poor and the suspected inequality of sacrifice.37 Diet by itself is only a part of the problem. As much as the deprived need to increase their intake of fresh vegetables, fruit, milk, eggs and fish, there is something more that is required – Tawney’s ‘common tradition’, Tawney’s ‘common culture’, Tawney’s ‘equality of environment, of access to education and the means of civilization, of security and independence, and of the social consideration which equality in these matters usually carries with it’.38 Clark and Titmuss built on Tawney’s Equality. They did so in order to argue that folk like the British would be especially motivated to fight the giants from abroad if the giants on their doorstep could also be put to rout. It was in this spirit that Clark and Titmuss called for a planned food policy that would include subsidisation of the staples most needed by those most in need. Schoolchildren should be given free school meals, an apple and a pint of milk. Pregnant and nursing mothers should be assisted to correct deficiencies of calcium and

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Richard Titmuss

phosphorous before they passed on to their children the free gift of dental caries. What all of this adds up to is the political lead: ‘A government which exerts itself to feed the people will be also a truly democratic government.’39 Only a year later, in July 1940, the milk and the meals had become a fact; and so had the immunisation against diphtheria of what was to be 7 million schoolchildren by the end of the war. It would be wrong to say that Our Food Problem was the cause. What is clear, however, is that it said what many were thinking – not least Sir Richard Acland, who used his position as Liberal MP to collect information for the book by means of Parliamentary questions – and that it did so with the mix of commitment and data that Titmuss was to make his trademark.

In 1942 came Parents Revolt. It is the only book jointly authored (although Richard appears to have written almost the whole of the text by himself) by Richard and Kay. There had been a significant decline in the birth-rate and, with it, in the population in a number of countries. The list included France, Germany and the United Kingdom. In the decade in which Keynes had written so persuasively about macroeconomic failure, a further debate had emerged on the possibility of a socio-biological failing that could prove in the long run to be just as much a cause for concern. The decline had been the subject of The Twilight of Parenthood (1934) by Enid Charles, Crisis in the Population Question (1934) by Alva and Gunnar Myrdal (published in Swedish only), The Struggle for Population (1936) by David Glass; and, of course, of Titmuss’s own Poverty and Population. In 1942 (the same year – the authors could not have known this – as the revival in birth-rates began) the Titmusses resumed the discussion. The decline in the birth-rate, they said, was ‘of even more vital importance to the destiny of man than the tragedy of war’.40 Still childless after five years of marriage, Richard and Kay must have known that they themselves formed part of the Parents Revolt that was the title of their book. Their only child (born when Kay was 39 and provisionally called Adrian in advance) must have been conceived at the same time as many reviews and a BBC discussion (headed ‘Too Few Babies?’) were making Richard’s name ever better known. Central to the debate are, of course, the aggregates. The net British reproduction rate in the 1930s, the authors reported, was 0.74–0.78. The British population was evidently not replacing itself. One consequence was the rise in the average age of the

Introduction

13

population and therewith in the burden of late-life dependency. In 1876, 5 per cent of the British population was aged 65 or above. In the early 1940s the figure stood at 9 per cent.41 Not only were the numbers of Britons contracting but those who were working were becoming responsible for an expanding cohort of those who were not. Premature deaths as well as prevented births can be a cause of falling numbers. Here once again it might be economic deprivation that was draining Britain of its strength: ‘War kills people, and poverty results in premature death.’42 Social reform in such circumstances could conceptually put right the aggregates. Eugenics, however, seriously complicates the choices. The strict adaptationist, sorry to lose superior specimens but less tolerant of the chronically unfitted, would be sorely tempted to say that a quantitative fall could simultaneously be a qualitative betterment where it was primarily the dysgenic and the maladaptive who were tending to die young. Titmuss (who in this period was in sympathy with voluntary sterilisation for the chronically unsuited) knew that premature deaths could be an indicator of natural selection: the ‘gloomy view’ of Galton is ‘exaggerated’, Parents Revolt declares, but ‘it does contain some truth’.43 The real problem is to separate the dysgenic from the merely disadvantaged. Nurture being so unequal and so capricious, the Titmusses argued, the fact is that nature itself is not visible but hid in night: The harmful effects of malnutrition, overcrowding, industrial working conditions, inadequate education and insufficient air, sun and leisure on physical and mental health so complicate the issues that . . . until there is far greater social and economic equality we shall not be able to point out particular groups whose fertility is harmful to the community.44 As things stand, we simply do not know. Given the lack of knowledge, common sense points to an equalisation of opportunity such as at the very least is likely to deliver an improvement in the population total. Birth-control makes possible the conscious choice of family size. Birth-control in that way makes endogenous and attitudinal the very survival – or extinction – of the British people. The middle classes have taken the lead in refusing to supply new Britons in quantities adequate to serve their nation’s need: ‘If the common people had restricted the size of their families in the same way as the well-to-do, Hitler’s Wehrmacht might by now be goose-stepping

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Richard Titmuss

down Whitehall.’45 Not enough soldiers, not enough producers, not enough consumers, not enough ‘folk like the British’ – national decline was just down the road, and the reason was the capitalist economy: ‘Capitalism is a biological failure.’46 Marx’s Capital argues that the free-enterprise system contains the seeds of its own destruction. Parents Revolt makes the same telling assessment: ‘The age of economic man – of competitive, acquisitive goals, is breaking down . . . Nothing shows this more completely than the fact that man is refusing to reproduce himself.’47 The middle classes already on strike, the working classes likely soon to emulate them, it was the message of Parents Revolt that the population problem would not and could not be resolved so long as ‘Will it pay?’ took precedence over ‘Is it right?’ in an economic order that depended on selfishness and greed. The sub-title of Parents Revolt – ‘a study of the declining birthrate in acquisitive societies’ – gave a warning that the book was not just about how many and which but about a why that, as with Marx, was the internal contradiction of possessive individualism. Beatrice Webb, asked by Richard to contribute a Preface, saw precisely what the book was about. On the one hand, she wrote, it was about the ‘public danger . . . threatening the survival of the white race’.48 On the other hand, she continued, it was about the rule of ‘Every man for himself and devil take the hindmost’ that was causing parents in capitalist societies to make excessive use of family planning. The ‘new civilisation’, Beatrice Webb observed pointedly, was setting a better example. The population of the Soviet Union, where public-spiritedness had replaced the man-made evil of narrow gain-seeking, was increasing rapidly: ‘By the end of this century, its population may be some three hundred millions of well educated and healthy human beings.’49 The Soviets had wisely begun with the economic basis. Because they had had a proletarian revolution there was no need for a parents’ revolt. The Titmusses (who showed no interest either in the Soviet Union or in the proletarian revolution) were absolutely clear that the birthrate had fallen because of the imperatives of the economic basis: ‘The combative nature of the economic system itself determined the choice. Children went out of fashion because they had no place in the scheme of things.’50 People in an acquisitive society judge themselves by what they can buy: clearly, children must be an ‘expensive liability’51 where esteem and standing are so much the results of outward display and conspicuous consumption. People,

Introduction

15

moreover, experience a perennial insecurity in a competitive economy: unstable employment, recurring unemployment, a shortage of living space, all militate against new responsibilities so long as poverty remains an ever-present possibility. Where altruism is expressed, it is in such conditions prudently confined to the members of the immediate family. Parents practise family planning in order to give a smaller number of offspring a better start in life. Conscientious as this might seem to some, it is also a selfish and an irresponsible action when seen from the perspective of a Britain becoming inexorably less Great over time. Possessive individualism is the cause. The transcendence of isolated ambition is the cure: ‘We have got to progressively eradicate the profit motive from society; we have to go forward to a real economic democracy based on co-operative values and we must offer something more compelling than the goal of economic prosperity.’52 Parents will simply not see the need to contribute sufficient children to the national pool so long as they lack the sensation of felt citizenship and purposeful integration that alone can make the cell use its freedom to choose the whole: A decisive attitude on the part of the majority to the population problem can only come about on the basis of a kind of identification of the individual with the people. The individual must not only feel but know that he is working and living not for himself alone but for the community . . . He must know that his children will be welcomed by the community as free contributions to the public good. He must begin to trust – and not distrust – the community.53 Lonely separateness leads to contraception as it does to suicide. Unity and neighbourliness, ‘a feeling of nationality, a sense of belonging to a national group’, is, on the other hand, ‘a prophylactic’54 – against both. The message of Parents Revolt is evidently a recommendation not just for more wanted children but for ‘the right viewpoint’: ‘We must look at things in terms of men and women, and not in terms of money.’55 This is not to underestimate the contribution of welfare reforms like family allowances, only to assert that ‘money is not the answer’56 and that income transfers superimposed upon economic values would do little to fill the moral vacuum of the times. As Titmuss had declared in the New Statesman in the year preceding the publication of Parents Revolt:

16

Richard Titmuss

Man’s desire to serve the community – and one way in which he can best do this is by consciously and deliberately desiring the continuance of his own kind – has been increasingly negatived by a society which tells him to seek his own interest, individually and nationally; to regard wealth as an index of biological success . . . For a century we have preached the value of morals and practised the immorality of acquisitiveness.57 Greatly influenced as he was by Tawney’s Equality, it is clear that Titmuss had absorbed the lesson of Tawney’s Acquisitive Society as well – that ‘if society is to be healthy, men must regard themselves, not primarily as the owners of rights, but as trustees for the discharge of functions and the instruments of a social purpose’.58 It was precisely this stewardship that the capitalist economy was normatively incapable of delivering. Titmuss at approximately the same time as the publication of Parents Revolt switched his allegiance from the Liberal to the Labour Party. This was a more radical choice then than it would have been a decade later. Parents Revolt uses the birth-rate as a sensitive social indicator in the same way that The Gift Relationship was much later to use the donation of blood. Both books introduce a microsociological discrimination (middle-class fertility in the former case, Skid Row ‘ooze for booze’ in the latter) alongside the quantitative totals. Both books address the ‘free-rider’ temptation that imperils the supply of the textbook economist’s ‘public goods’ – Britons in 1942, transfusions in 1970 – through an appeal to altruism, commitment, community and duty. Both books contend that market capitalism can act to repress the freedom of choice, can be incompatible with ‘biological need’ and ‘biological success’, can be a cause of social division and personal emptiness. The Gift Relationship is rightly regarded as a classic at the interface between social science and social philosophy. Parents Revolt deserves to be more widely read as the early attempt of the same original thinker to explain the coordination of millions of individual decisions by means not of prices but of attachments and of norms.

Between 1939 and 1942, still employed at County Fire, Titmuss worked on German vital and medical statistics, advising the Ministry of Economic Warfare after 1941 on the impact of the war on the health status of the Germans. He showed that mortality indices

Introduction

17

in Germany had actually risen since 1933. This was in contrast to Nazi propaganda, which had made much of the effectiveness of German social policies. From 1939 to 1941, also in his spare time, Titmuss was continuing his research on demography and eugenics. His research was supported by a small grant from the Leverhulme Trust. The outcome of his investigations was Birth, Poverty and Wealth, published in 1943. As before in his work, Titmuss took for granted the reality and the significance of the genetic constitution. As before in his work, Titmuss refused to assert that the British experience confirmed the weeding out of bad genes and the beneficial selection of good: ‘In all the major causes of death in this country there is little or no evidence of important hereditary factors.’59 Nature can be the cause of schizophrenia and epilepsy. Nurture, however, can lie at the root of tuberculosis and influenza. Trapped between the biology and the sociology, Titmuss in 1943 reported that his earlier assessment of unequal opportunity still appeared to him sound: ‘Inherited intelligence has not the full opportunities for development in an evil environment or when nutrition is inadequate.’60 In Birth, Poverty and Wealth Titmuss used statistical data from many sources to show that premature death was most likely in the lowest occupational groups, least likely in the highest: ‘On the basis of the latest available social class mortality data we see that the mortality of Class V exceeds that of Class I by 161 per cent.’61 As with the occupational gradient, so with the North–South divide upon which it was superimposed: ‘Looking at the regional extremes we see that while Class V mortality exceeded that of Class I in the South-East by 63 per cent and the South-West by 67 per cent, in North 1 the excess was 166 per cent and in North 4 it was 198 per cent.’62 The differentials as measured by the Registrar-General’s five broad categories (work function here serving as a proxy for income group and social status) and by the standard geographical circumscriptions – themselves an indicator of ‘the much more depressed economic conditions of the poor in the North’63 – could, of course, have been the consequence of innate differences in physical and mental fitness alone. They could, on the other hand, have been the result of slum density, insanitary sewers, threadbare clothing, insufficient food, inaccessible doctoring – of poverty, in other words, such as condemns the deprived to high infant mortality and to wasteful underperformance: ‘Wealth opens the door of opportunity while poverty keeps it closed from the cradle to the grave.’64

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Richard Titmuss

Titmuss knew that the evidence did not allow him to be dogmatic about the relative importance of heredity and environment. He also knew that his unique position as a eugenicist and a socialist, a statistician and a philosopher, made it indispensable for him not to dwell too long on the fence. It is possible that his conclusion was too confident. It was, however, the only conclusion that a follower of Tawney and a contemporary of Stockton could reasonably have reached: ‘The fact that for every eleven infants of the economically favoured groups who die from preventable causes, 90 children of the poor die from similar causes summarises, as a matter of life or death, the power of environment and economics.’65 And not, apparently, of genes. Even so, the Eugenics Society was prepared to support publication of Birth, Poverty and Wealth through a grant of £100. Macmillan turned down the proposal (they had decided to concentrate on commercially attractive manuscripts for the duration of the war) and Titmuss’s fourth book moved on to Hamish Hamilton – his fourth publisher. Titmuss’s book (soon supported by three papers written with J.N. Morris on the social origins of mortality from rheumatic heart disease and from stomach ulcers) looks forward to the mature analytic of his later work. It also looks backward to his earlier concern with a declining population. In Birth, Poverty and Wealth Titmuss showed that social inequalities as measured by the disparity in infant deathrates between the most and the least privileged social classes was ‘as high as, if not higher than, before the 1914–18 war’. 66 He calculated that if all classes had had the same infant death-rates in 1930–32 as did social class I, then 90 000 infants would not have died. Even after allowing for the welcome fall in the absolute levels, a loss of 90 000 lives in consequence of a reducible gap must be regarded as a topic in collective survival and not just in individual fitness at a time when Hitler’s Wehrmacht was already contemplating its goose-stepping down Whitehall. Tawney in his path-breaking Ratan Tata lecture had in 1913 proclaimed deprivation another name for maldistribution: ‘What thoughtful rich people call the problem of poverty, thoughtful poor people call with equal justice the problem of riches.’67 Titmuss, at the time when Birth, Poverty and Wealth marked the end of his apprenticeship years, had, like Tawney, come to see poverty as the obverse of wealth – and as an economic failing which a sensible society would do well to correct. In the free-market past, self-centred, ostentation-chasing, money-worshipping, poverty had been seen as

Introduction

19

a ‘part of the landscape’: ‘To most, poverty, or the inequal distribution of wealth, was quite natural in an age when every man was taught to promote his own self-interest.’68 That was the past. The future was yet to come.

At the outbreak of war Titmuss had been deferred from conscription because his occupation of Insurance Inspector and Surveyor had been made a reserved one. Titmuss was involved in war-risks and war-damage insurance. In that capacity he made visits to bombedout premises and talked to people who had lost their homes. The Cabinet Office was assembling a team of historians to write the civil history of the Second World War. Unusually for an official record, the events were to be monitored as they unfolded and not simply reconstructed in tranquil hindsight later. The leader of the group was to be W. Keith (later Sir Keith) Hancock, an economic historian at Birmingham University. Eventually some thirty volumes were to appear. Titmuss was by no means unknown. There had been the articles in The Times, The Lancet, The Spectator, The Insurance Record, The New Statesman; the editorship of the Eugenics Review; the four booklength investigations into neediness and numbers which had demonstrated such scrupulous attention to detail. Titmuss was a Fellow of the Royal Statistical Society and the Royal Economic Society. He was on the Council of the Eugenics Society. He had been approached in the war by the Ministry of Food and the Ministry of Information. On the other hand, he had left school at 14 and had no formal qualifications. Hancock had heard of Titmuss from Eva Hubback, Principal of Morley College and a Council member of the Eugenics Society. Hancock was impressed by the self-taught enthusiast and not deterred by the lack of public-school – or even state-school – credentials. Perhaps the fact that Hancock was Australian made him more open to merit and more resistant to the Oxbridge self-presentation of the career civil servant. His decision to invite Titmuss to join the team showed courage but also remarkable prescience in the light of the use that Titmuss was to make of this piece of good luck. County Fire refused to give him unpaid leave and, signing the Official Secrets Act, he resigned. Titmuss joined Hancock’s group in 1942. He was to be concerned with social services (ranging from the evacuation and billeting of

20

Richard Titmuss

mothers and children to health, social security and the care of the homeless). The project was to occupy him until 1949. The war years must have been especially exhausting. Doing his research in the daytime, he and Hancock spent one night a week as firewatchers at St Paul’s. Looking back on the rum consumed in an unconsecrated corner, the bath and breakfast at the Cabinet Office before doing a day’s work, Hancock later wrote: ‘Even during the war, I think that the crypt of St Paul’s on Wednesday nights was the best club in London.’69 Titmuss was one of many British people who found in unpaid activities such as firewatching the camaraderie, the equality of respect, the sense of belonging which for them was the essence of the One Nation ideal. Just as the Depression had shown how social forces could generate vast unrelieved states of dependency, so the war was proving that men and women in society could work together in pursuit of a common aim. As the Queen said when a bomb shattered the windows of Buckingham Palace: ‘It makes me feel I can look the East End in the face.’ Richard and Kay must have felt much the same way when their own small home in Pimlico was bombed out in the Blitz. Titmuss’s contribution to the series, Problems of Social Policy, was published in 1950. Because the failures as well as the successes were impartially depicted, Hancock had to threaten to resign for the Ministries to withdraw their objection to the volume. In his book Titmuss showed mastery of vast quantities of material, some from official publications but much or most collected directly from government departments and a wide range of welfare institutions. Unlike many historical works, Problems of Social Policy was sensitive at all times to moral dilemmas, value choices and the human dimension. Insightful and well written, it ultimately sold more copies than any other volume in Hancock’s series. R.H. Tawney regarded it as little short of brilliant: Sociology, like history, is a department of knowledge which requires that facts should be counted and weighed, but which, if it omits to make allowance for the imponderables, is unlikely to weigh or even to count them right. Mr. Titmus [sic] is a humane scientist who does not succumb to the temptation to ‘measure the universe by rule and line’. His subtlety and insight in interpreting his evidence are as impressive as the meticulous scrupulousness with which he has collected and sifted it.70

Introduction

21

In 1945 Titmuss found time for the Report on Luton. It was prepared for the Luton Borough Council and written in collaboration with Dr Fred Grundy, the local Medical Officer of Health (who happened to be a qualified barrister as well). For their Report the authors conducted a statistical survey of Luton’s population (sampling one household in every ten). In that way they built up a picture of social life and social conditions – housing, health, education, migration patterns, age structure – which they rightly regarded as the factual basis upon which any policy infrastructure would have to build. Titmuss’s unique contribution is visible in a number of places. Not the least of these is the section on the finance of social services. There, discussing the ‘function of money in society’, the Report concludes that the budget can never be more than ‘a means to an end’: ‘Policy should not be determined mainly according to money resources. It may, indeed, be argued that if we cannot afford these services we must have them; if we could easily afford them, many would be unnecessary.’71 Written in the year when Labour’s victory heralded the cradle-to-grave security that had been eagerly awaited since Social Insurance and Allied Services in 1942, those words reiterate the core pledge of Titmuss’s commitment to care – that no citizen should ever be denied a decent lifestyle simply because his community is too mean to pay. The civil service period at an end, from 1949 Titmuss was free to devote himself full-time to research projects like the Report. In 1949–50 he served as the Deputy Director of the Social Medicine Research Unit of the Medical Research Council. He also explored (with Hancock’s help) the possibility of an academic appointment at All Souls’ or Nuffield. The prospect was one which he contemplated with some trepidation. Titmuss was acutely aware that he was deficient in social location and university culture. His feelings of inferiority, his moods of self-doubt, are well illustrated by a letter written to Jerry Morris not long before the Report: I have had the ‘glooms’ lately and badly . . . My particular worry is, broadly, education. It gets a bit tiresome, you know, to be constantly meeting people who will talk about things on which you know literally nothing. I am always being reminded about this ‘educational inferiority’. It applies to literature, history, ‘the arts’, and, nearer home, to statistics. It sometimes makes me despair of getting, and holding, a worthwhile job after the war.72

22

Richard Titmuss

Ann Oakley suggests that there may even be a link between Titmuss’s own second-bestness, self-perceived, and the deep sympathy he felt for society’s outcasts and also-rans: In discovering the huge disparities in life chances between those at the bottom and those at the top of the social scale, he was at the same time commenting on his own lack of fortune in not being born at the top. Awareness of class was central to his intellectual perception of society. But it was also constantly felt as an aspect of his own life.73 Titmuss need not have worried about getting, and holding, a worthwhile job after the Problems. New professorships in social policy were being created in London and Birmingham in response to the expansion in the social services. Titmuss was approached for both. The result was that, in 1950, he was appointed to the new Chair of Social Administration at the London School of Economics. T.H. Marshall had tried even before publication of the Problems to secure him for the School and Hancock wrote an enthusiastic recommendation. The Director of the School, Sir Alexander Carr-Saunders, knew Titmuss through the Eugenics Society. He was sympathetic to the appointment despite Titmuss’s lack of a university degree. Given the nature of the post and the small number of reputable investigators in 1950 with an interest in social policy, Titmuss is unlikely to have been in competition with any very strong rivals. The Chair was Titmuss’s first (and only) academic post. Much of the freshness of his work may indeed be due to the fact that he never had to conform to the rigidity of departmental conventional wisdom in order to secure a job or win a promotion. Titmuss was a maverick and an outsider. According to Ann Oakley, he derived great satisfaction from the freedom to trespass which his self-selected multidisciplinarity was able to offer him: ‘His work was always difficult to classify (a fact of which he himself was obstinately proud), and, since he had no professional academic training, he persisted in calling himself a student of society. He always began with a problem and worked outwards to an analysis of it.’74 Just as Titmuss was fortunate that he had no strong rivals for the Chair, so he was in luck that research assessment exercises and audit by peer-refereed publication did not yet exist to constrain innovation within the time-worn grooves. In 1950 the London School of Economics, although formally a

Introduction

23

part of the University of London, had no natural scientists and few arts staff. It was almost entirely a social science college. The continuous debates on the issues of the day must have been a source of considerable stimulus – and benefit – to a newly enfranchised autodidact who found even multiple regression a new discovery. The lack of a degree proved no obstacle to recognition in the long run. Titmuss eventually received five honorary doctorates – from the University of Wales (1959), Edinburgh (1962), Toronto (1964), Chicago (1970), Brunel (1971) – and was about to receive a sixth (from Brandeis) at the time of his death. He was made a Commander of the Order of the Dannebrog (in Denmark) in 1965 and a Fellow of the British Academy in 1972. In 1966 he was awarded the CBE. Later he was offered, also by Harold Wilson, a life peerage. Like Tawney before him, he declined. Always refusing to travel first class on the railways, he presumably believed that it would isolate him too much from his fellow citizens. Kay was disappointed, observing late in life that ‘there’s only one thing I regret, that I wasn’t Lady Titmuss’.75 Interestingly, their daughter Ann was educated from 11 to 16 in the private sector at a grant-aided school (she herself had a state-funded place but one-third of the pupils were fee-paying) and later at Oxford. Looking back, Ann had this to say about a man who had a love–hate relationship with some parts at least of Britain’s historic Establishment: ‘You didn’t have to be a detective to discern my father’s concealed adulation of certain unsocialist institutions.’76 In 1950 Titmuss inherited from T.H. Marshall a strong department of 13 members. Most were trained social workers, looked down upon in the School to such an extent that as late as 1949 they were paid on a lower salary scale. Titmuss, of course, was not a social worker; and his brand of administration, as opposed to casework, undeniably brought him into conflict with some of his more task-centred colleagues. The conflict was to some extent resolved when it was realised that his interest in policies and politics was accompanied by a real commitment to vocational social-work education. He also won admiration from many of his associates for the institution of reforms such as the admission of older students without formal educational qualifications. At the London School of Economics, supported by core ‘Titmice’ like Brian Abel-Smith and Peter Townsend, Titmuss moulded the new subject of Social Policy and Administration and demonstrated that it could be both academically and intellectually respectable.

24

Richard Titmuss

Rose is right to say that ‘the growth of social administration over the fifties and sixties was paralleled by the spread of the paradigm and the people from the Titmuss school’.77 Not only did the LSE Department train a disproportionate number of practitioners, British and foreign, but the acknowledged vanguard was called upon with disproportionate frequency to advise other departments on the Chairs they should select: ‘Kingmaking within the newly developing departments of social policy took place actively.’78 Peter Townsend was appointed to the first Chair of Sociology at the new University of Essex. Brian Abel-Smith, David Donnison and Della Nevitt were given Chairs at the LSE. Roy Parker became Professor at Bristol, John Greve at Southampton. The inference to Rose is clear enough: ‘At its height the Titmuss school reigned unchallenged over the construction of social policy.’79 The downside of the hegemony is, however, a self-reinforcing complacency which is never very beneficial for the health of a field of study. Pinker writes as follows of Titmuss and the respect which his authority could command: ‘During his lifetime his work was only very rarely subjected to reappraisal by other scholars within the discipline.’80 Titmuss is not to be blamed for the zeal of his disciples. It must, however, be conceded that a commanding figure in any subject must always be a threat to diversification and to change. At the LSE Titmuss had a high profile on committees and boards. He was noteworthy for his approachability, his modesty and his simplicity. Although very hard-working, he was never too busy to comment on or discuss the work of others. Violence and disorder were, however, always anathema to him. In the troubled years of 1966–68 he joined forces with right-wing economists like Lionel Robbins in opposing New Left activists such as Robin Blackburn (who was dismissed from his lectureship) and student radicals who failed to recognise that democratic socialism could have no worthwhile future save in the historic context of tolerance and respect, debate and persuasion, hierarchy and discipline. Titmuss was more than just an academic. While the main lines of the modern British Welfare State were laid down before he became influential, he acted, while a professor at the London School of Economics, as adviser to the Labour Party on policy issues such as pensions. He was bitterly disappointed when Labour’s new national superannuation scheme was lost in 1970. Had the election of that year which ended six years of Labour government been called only a few months later, the Bill would have become an Act.

Introduction

25

Outside party politics, Titmuss sat on a number of government committees. These included the National Insurance Advisory Committee, the Royal Commission on Medical Education, and the One Parent Family (Finer) Committee. Titmuss and his close associates, partly because there was not much challenge, institutional or intellectual, were strongly represented in the preparation of policyrelated reports throughout the period of their leadership. Titmuss demonstrated his interest in race relations by serving on the Community Relations Commission (from 1965 to 1971) and in the problem of poverty by acting as the Deputy Chairman of the Supplementary Benefits Commission (from 1966 to 1973). This last post is a surprise as supplementary benefits were means-tested and Titmuss was a vociferous enemy of the means test. Perhaps, however, as Margaret Gowing believes, ‘he saw the Commission’s work as one way of exercising the positive discrimination in favour of the underprivileged which was necessary on top of universalist benefits’.81 Titmuss was interested in the problems of poor countries and set up at the LSE the first course in Britain in development administration. In his writings he stressed that developing countries, in their quest for economic growth, should not neglect the indicators of social growth as well. He repeated this point in the recommendations he made to the governments of Tanganyika (where he and Julius Nyerere found that they shared a common vision of equality and nation-building) and Mauritius.

Titmuss did not live to be ‘eccentric in old age’ as he had hoped. He died of cancer in a national health hospital – the Central Middlesex, near his home at 32 Twyford Avenue, Acton – on 6 April 1973. He was 65. Over one thousand people attended a memorial service for him at St Martin-in-the-Fields on 6 June. The speakers were Richard Crossman (previously Secretary of State for Social Services in the United Kingdom), Wilbur Cohen (previously Secretary at the Department of Health, Education and Welfare in the United States) and the Rt Reverend Trevor Huddleston, socialist Bishop of Stepney. Julius Nyerere sent a message of condolence. So did Sir Keith Joseph. Trevor Huddleston called Titmuss ‘anima naturaliter Christiana’ and said that he exemplified the true Christian values. Richard Crossman paid tribute to his commitment to welfare: ‘Richard Titmuss was not like other men. His eyes and his conversation shone with a

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Richard Titmuss

moral force.’82 It is indeed that moral force which more than anything else characterises the intellectual system that is analysed in the chapters of this book. As Paul Wilding has put it so well: Titmuss’ work put moral and philosophical issues at the heart of debates about the welfare state, and gave them a central place in the academic study of social policy. Social policy could, very easily, have become preoccupied with the study of the nuts and bolts required to achieve certain ends. Titmuss’ legacy ensured that this would not happen.83

Part One: The Status of Social Policy

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2 The Definition of Social Policy

All policy means choice involving change. Policy by its very nature implies that we ‘believe we can affect change in some form or another. We do not have policies about the weather because, as yet, we are powerless to do anything about the weather.’1 Yet, precisely because it cannot escape the constraint of choice involving change, precisely because it is action-oriented and problem-oriented, no policy can escape from values, ideologies and images of what constitutes the ‘good society’. Titmuss stressed that human values cannot be ignored in any meaningful discussion of social policy. Since in the last analysis, ‘social policy is all about social purposes and choices between them’,2 it was obvious to him that it could never be ‘value-free’: We all have our values and our prejudices; we all have our rights and duties as citizens, and our rights and duties as teachers and students. At the very least, we have a responsibility for making our values clear; and we have a special duty to do so when we are discussing such a subject as social policy which, quite clearly, has no meaning at all if it is considered to be neutral in terms of values.3 Social policy has its origins in the values of a particular society. It ‘cannot be discussed or even conceptualised in a social vacuum’.4 Welfare systems tend to ‘reflect the dominant cultural and political characteristics of their societies’.5 They must be seen ‘in the context of a particular set of circumstances, a given society and culture, and a more or less specified period of historical time’.6 Social policy, in short, is social because and where needs are defined to be social: ‘All collectively provided services are deliberately designed to meet 29

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The Status of Social Policy

certain socially recognized “needs”; they are manifestations, first, of society’s will to survive as an organic whole and, secondly, of the expressed wish of all the people to assist the survival of some people.’7 This is an important statement. There are two crucial points to note. First, social policy is concerned with those needs which must be satisfied if the existing social matrix is to continue in existence. It is thus group policy not just in its origins but in its functions as well, since it has a deeply integrative and communitarian objective. Hence the primary areas of unifying interest for social policy ‘are centred in those social institutions that foster integration and discourage alienation’.8 Its model is the gift or unilateral transfer rather than the exchange of equivalents or the quid pro quo. Titmuss believed that social policy is ‘profoundly concerned with questions of personal identity whereas economic policy centres round exchange or bilateral transfer’.9 He went still further to assert that, save in terms of its aims, objectives and ends, there is no consistent definition of social policy.10 It is not, in short, particular institutions themselves that make up social welfare but their functions within the social structure: ‘The definition, for most purposes, of what is a “social service” should take its stand on aims; not on the administrative methods and institutional devices employed to achieve them.’11 Second, social policy is concerned with those states of dependency which are generally recognised by the collectivity to be collective responsibilities: ‘These “states of dependency” arise for the vast majority of the population whenever they are not in a position to “earn life” for themselves and their families; they are then dependent people.’12 The reasons for the dependency might be related to the life cycle (as in the case of the very young or the very old), the mind (as in the case of the psychologically ill), the economy (as in the case of unemployment created by regional policies). The dependent person might not even recognise all the social needs that are being met. An urban black, for example, might desire medical attention which has the manifest function of making him well, and yet find that care in an integrated ward where the same universalist benefits are available to all will also make him feel happily integrated, a latent function which he did not anticipate. Such integration is an example of a benefit to the community in its own right. It is conceptually independent of any benefit that may accrue to the individual. Other social needs affecting the community as a whole might be for the probation services, law and order, or the prevention of infectious diseases. The need for equality itself,

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in Titmuss’s view, comes into this category. The justification for equality is to be sought in ‘the will of society to move towards a more equal society’, and its extent is to be governed by the rule ‘to each according to our needs’.13 The needs, work, merit or worth of the individual are relevant only to the extent that they are refracted through the whole. Both points that have just been considered suggest that the amount and nature of assistance offered under the heading of social policy will depend ‘on prevailing notions of what constitutes a “need”’14 (and on how far the group as a whole is to be held responsible for satisfying it). Historically and comparatively, ‘no consistent principle seems to obtain in the definition of what is a “social service”’.15 For modern Britain, however, we may induce the following from experience. In modern Britain the discipline called ‘Social Policy and Administration’ is concerned with identifying social needs and with the structure of administration necessary to satisfy them. It studies the nature and distribution of social benefits and social costs; the rights and duties of the citizen both as contributor to and consumer of the social services; the interaction between the three systems of welfare that constitute collective intervention to meet selected needs (social welfare, occupational welfare and fiscal welfare); and the command-over-resources-over-time. It identifies the present-day social services as involving state education, local authority housing, social security, the National Health Service (both in its preventive and its curative role), and other directly administered services and transfer payments. The benefits can be in cash (for example, old age pensions or unemployment benefits) or in kind (for example, hospital services), but in all cases the government and not the economic market is the allocating agent for rights, duties and collective consumption and the objectives are wherever possible emerging as the following: ‘Social policy in Britain in the personal health, welfare and education fields is moving toward integrated community services, preventive in outlook and of high quality for all citizens in all areas irrespective of means, social class, occupation or ethnic group.’16

This is the state of affairs in modern Britain. Yet, because values and priorities are pre-eminently social facts, it is understandable that the scope for collective provision is elastic and that the role of social policy in practical terms varies from period to period and place to place.

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The Status of Social Policy

Consider first variation over time in the sort of policies that should be ‘social’. Here Titmuss records a change both in the underlying nature of social reality and in popular attitudes: ‘The Britain of the 1950’s is a very different society from the Britain of the 1900’s. Not only are the “needs” and “situations” different but they are differently seen.’17 Naturally, ideas go deep into the past (witness the vestigial influence of the Poor Laws, or of the crude utilitarianism of Economic Man), and in that sense ‘reality starts with history’.18 Yet, despite the fact that ‘we all drag about with us the chains of history’,19 changes in phenomena and perception do take place. Such changes in the field of welfare have been brought about by both intellectual and material forces. An example of the former would be the influence of Marx, Freud or democratic socialists such as Tawney. An example of the latter would be the technological revolution or the revolution of rising expectations. As is well known, ‘rising standards of living and of education have shifted the emphasis in social services from quantity to quality’.20 This process has been accelerated by the inclusion of the middle classes in the Welfare State, stridently demanding services of the standard to which they would like to be accustomed and thereby generating a bonus for the lower classes. This illustrates how the definition of adequacy and the specification of priorities are still in a process of evolution and are being shaped by social factors. Titmuss believed that social thinking on matters of welfare in the twentieth century had been considerably influenced by war. In the Second World War, for example, the evacuation of mothers and children led to reports of lice, skin diseases, undernourishment, poor clothing, and exposed the extent of bad housing and poverty: ‘The shock to public opinion over the condition of some of the evacuees rivalled the outcry after the Boer War with its disclosures of sickness and low physical standards.’21 Again, the cooperation of the masses and social integration in wartime are only possible if marked differences in the population (say, in the ability to afford luxury entertainment) are reduced: ‘The waging of modern war presupposes and imposes a great increase in social discipline; moreover, this discipline is only tolerable if – and only if – social inequalities are not intolerable.’22 Then, too, war shifted the emphasis away from ‘a philosophy which regarded individual distress as a mark of social incapacity’23 and towards a more altruistic approach according to which new forms of assistance were to be offered without social discrimination to all groups in the population on the basis

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of ‘the pooling of national resources and the sharing of risks’.24 Hitler’s bombs succeeded where the Depression of the 1930s had failed, in imposing a de facto structure of universalism in a multitude of welfare benefits. After all, the diswelfare costs were demonstrably universal as well: ‘That all were engaged in war whereas only some were afflicted with poverty and disease had much to do with the less constraining, less discriminating scope and quality of the war-time social services. Damage to homes and injuries to persons were not less likely among the rich than the poor.’25 Nor, incidentally, was the need for adequate widows’ pensions or the use of rehabilitation centres. This too, presumably, meant greater tolerance by the rich of adequate rent subsidies for the poor. Such subsidies covered the same sort of socially imposed costs as the benefits which the rich themselves had begun to receive. The drift into tolerance was further stimulated by the highly desirable sense of community that came about as a result of wartime setbacks, bombing, and a clearly defined sense of common purpose. Titmuss, like many others of his generation, welcomed the changes in social values and social policy that were induced by the spirit of Dunkirk. He argued that in the summer of 1940 ‘the mood of the people changed and, in sympathetic response, values changed as well. If dangers were to be shared, then resources should also be shared.’26 Dunkirk was a milestone in the history of the social services since it unleashed a flood of critical debate and national introspection. It caused even The Times to call in a Leader on l July for tighter social organisation, better economic planning, and more equitable conditions of income distribution: If we speak of democracy, we do not mean a democracy which maintains the right to vote but forgets the right to work and the right to live. If we speak of freedom, we do not mean a rugged individualism which excludes social organisation and economic planning. If we speak of equality, we do not mean a political equality nullified by social and economic privilege. If we speak of economic reconstruction, we think less of maximum production (though this too will be required) than of equitable distribution.27 The Times, writing of the preconditions for justice in wartime, seemed to be formulating a theory of the just peace as well.

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In July 1940 the Treasury took steps to improve the number and quality of school meals and to ensure that more milk be provided for expectant and nursing mothers and young children. It is significant that this decision was taken only five days after the Dunkirk evacuation, and that these early steps were followed by numerous other measures. These included the provision of cheap or free supplies of orange juice and cod liver oil and a nationwide campaign to immunise children against diphtheria. All of this is evidence to support Titmuss’s view on the Dunkirk evacuation: ‘The long, dispiriting years of hard work that followed these dramatic events on the home front served only to reinforce the war-warmed impulse of people for a more generous society.’28 The Second World War was immediately responsible for the Beveridge Report of 1942, the Education Act of 1944 and even the National Health Service in 1946. Titmuss, like Tawney, had a ‘historian’s eye to the future’.29 He was convinced that he had learnt a vital lesson from Britain’s wartime experience: people, once aware of the common situation which they share with their fellow citizens, will opt for non-discriminatory benefits available to all members of the crew, for services which will themselves increase still further the sense of belonging and integration. In this way the recognition of social duty, the perception of common humanity and the awareness of citizenship rights become cumulative over time. They are in turn fostered by the atmosphere of planning that results.

This chapter has been considering variations over time in the sort of policies that are regarded as being properly ‘social’. It will be useful now to consider variations from place to place. There is, after all, no absolute definition of what constitutes a social ‘need’. All that can be known is spotlighted by the specific standards that are shaped by a given society. The use of the comparative method reveals important differences in attitudes from one culture to another. Titmuss rejected those theories common in the 1950s and 1960s which postulated the death of ideology (in a world increasingly based on economic and technological rationality) and the imminence of convergence as between advanced industrial societies (due to similarities in technology and the exploitation of mass-consumption markets). The fact is that countries are not tending to become more and more alike ‘in terms of their dominant value systems and political

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ideologies’, as Titmuss’s own study of paid and unpaid blood donorship indicates: ‘This study throws doubt on such theories. There is no indication of convergence over the last twenty years in the pattern of blood donor gift-relationships when comparisons are made between the United States and Britain.’30 Blood-donorship patterns may be regarded as a useful index of social benefits and values. Titmuss uses an eight-point scale ranging from the paid donor at one extreme (motivated solely by the promise of cash compensation) to the voluntary community donor at the other (motivated by the altruistic desire to give to strangers regardless of what is offered in return) to make international comparisons of attitudes and ideas. His conclusions are unambiguous: ‘Different social and political structures and value systems strongly determine the typology distributions.’31 The differences between, say, Britain, Russia, the United States and Japan in blood-donorship patterns cannot be explained simply in terms of administrative and organizational structures of blood supply systems and patterns of medical care services. The causal factors are more fundamental than that; ultimately, explanations – and, admittedly, explanations that can never be more than partial – have to be sought in the history, the values and the political ideas of each society.32 The fact that there is not a unique developmental path to which all countries must willy-nilly conform is a source of freedom: ‘The sense of freedom and self-respect, implicit in the notion of purposive control over man’s secular affairs, can be diminished if it is believed that political choice has been narrowed to considerations of technique and administration.’33 Where there are no radical choices to be made, ‘political democracy becomes a device for choosing between different leaders but not between different social objectives’,34 and people’s ability to shape their own future is sadly diminished. The ‘end of ideology’ in the sense of Daniel Bell and of Galbraith is hence a most lamentable state of affairs. It reduces the range of choices open to a country to express its unique value-orientation, or to change its institutions as that value-orientation alters. Were ideology to drop out of the social welfare equation, the social policy-maker would be left with techniques but not values. Yet, since ‘policy, any policy, to be effective must choose an objective and must face dilemmas of choice’,35 social decision-makers

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are bound to feel confused without an ideological map capable of focusing their attention. Thus, ‘social policy models . . . with all their apparent remoteness from reality, can serve a purpose in providing us with an ideological framework which may stimulate us to ask the significant questions and to expose the significant choices’.36 Social policy presupposes social choices which presuppose social values. It must evolve from widely held attitudes rather than be imposed from above by a power élite. Societies, like individuals, must make choices. In a democracy these choices must be made collectively. Suppose, for example, that the decision-maker is confronted with a choice between equity and equality, between selectivity and universalism, between cost-effectiveness and social justice, between individual liberty and collective responsibility, or between the principle of charity and that of compensation. Suppose, in a concrete case, that he or she must decide whether an income maintenance scheme should be associated with compulsory retraining and rehabilitation (or, alternatively, be extended indefinitely to an alcoholic or an addict who refuses to bend his way of life to the consensual norm); or whether poor parents should receive cash supplementation (rather than payments in kind or in vouchers tied to specific purposes such as schooling or transport); or whether to means-test applicants for supplementary benefits (instead of providing these benefits as of right). In all of these cases science provides no more than a spectrum of choices and a unique answer can only be found by consulting the social matrix. The solution then depends ‘on the relative importance we accord to economic growth and social growth, and on how the scales are weighted between the rights of the individual and the rights of society’.37 Even the allocation of scarce resources by the market mechanism, to be legitimate, must be legitimated by social choice. It is therefore eminently plausible that the market will on occasion be rejected in favour of other social mechanisms of allocation, either because it undermines social integration or because it simply fails to meet ‘publicly acknowledged needs’.38

Social policy, as has been seen, is conservative in nature in so far as it is concerned with those needs which must be satisfied if the existing social matrix is to continue in existence. Yet it is also radical because of the wide range of choices (choices concerning both ends and means) that is open to a society in the shaping of its own

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future. Titmuss believed that social policy ought to be active rather than passive. It must, he said, function as the instrument of a ‘modern democratic society’ in achieving its collective goals: ‘Social security has to be seen as an agent of structural change; not as a system reflecting and legitimating the status quo.’39 A good example of the active social engineering role that Titmuss intended for welfare may be found in the advice he gave to the Government of Mauritius. The problem in Mauritius was an alarmingly rapid rise in population after the Second World War, caused by a sudden fall in mortality rates (following the virtual eradication of malaria and tuberculosis) and by an extremely high birth-rate. The latter was a social fact due partly to the low status of women (who married young since they were not expected to take jobs nor found it easy to obtain them) and partly to the social insurance function of a large family in a country without comprehensive pension provision. The result of the rise in population was unemployment, underemployment, pressure on state services such as education, and falling standards of living (measured in terms of gross national product per capita). When Titmuss went to Mauritius in 1960, the country had one of the most rapidly expanding populations in the world. Employment opportunities were not increasing at the same rate as the number of potential workers. Naturally Titmuss could not recommend an increase in mortality rates; and an increase in jobs, while desirable, was both a longterm measure and inadequate by itself if the population continued to increase so rapidly. Hence Titmuss’s solution was to reduce fertility. His proposals fall into two groups. First, he called for voluntary birth-control and recommended a nationwide campaign to provide free facilities and information. He advised that every cinema and newspaper should include an advertisement at least once a week on the benefits of the three-child family and bringing out the fact that family planning is essential for social progress. Showing considerable tolerance, however, he recognised the validity of religious objections to contraception and proposed that the new services should neither be compulsory nor prohibited: The right of any individual on religious or any other ground to refuse to use these services or any particular method of family limitation must be safeguarded. The right of those who wish to know and who wish to use the services must equally be upheld.

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The tolerances and courtesies of a liberal society must be practised by all. The illiberalities of some must not thrive on the courtesies of others.40 In their report to the Government of Tanganyika four years later he and his colleagues adopted an identical position. The State, they recommended, should help disseminate information about family planning (thereby giving the citizenry a legitimate choice by showing them how far births can be controlled), but it should not make the small family compulsory: ‘It is for the people of Tanganyika to say whether they would prefer to have fewer and stronger children than large numbers of undersized and sickly children . . . These are questions which parents must decide. They cannot be the subject of legislation or any form of regulation.’41 Secondly, Titmuss proposed the creative manipulation of the pattern of social benefits to help bring about an immediate change-over to the small-sized three-child family system that he regarded as essential to contain the Malthusian momentum. Thus he recommended that there should be a ‘Small Family Pension Benefit’ of an extra 15 rupees per month. This would be payable to a woman of 65 or over who had given birth to not more than three live-born children and thus helped to solve the community’s most pressing social problem. The proviso was that she was still married at age 65 and had married before she was 45.42 Again, a maternity benefit was to be provided to no woman who had borne a child (living or dead) within the 24 months before the expected date of the birth for which she was claiming. This would encourage the spacing of children. Some of the proposals were even more microscopic and targeted. No woman, for instance, was to receive maternity benefit if she was under 21 (to encourage a later start to families), or if she already had three living children (to keep down the size of families), or if her husband had in the previous year been assessed for income tax (to skew the benefits towards the poor), or if she could not prove she had access to information on family planning at an antenatal clinic (even if she did not in fact make use of contraceptive techniques).43 Titmuss also recommended a system of family allowances aimed at discouraging the large family. A benefit of 15 rupees per month was to be paid to each family with three dependent children under the age of 14. There was, however, to be no increase in benefit if the family had more than three children and no payment at all if

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there were less than three (the idea being that, in the absence of financial aid for their first or second child, would-be parents would postpone starting a family until later when they were richer).44 The system was to be non-contributory (so as to reach even the poorest members of the community). It was to replace tax allowances for children. These, because income taxes in Mauritius were progressive, were of greater value to the rich than to the poor.45 Titmuss went still further in harnessing social welfare in the service of society. He recommended that a non-contributory benefit of 50 rupees should on the occasion of a marriage be paid to the father of the bride where both bride and groom were 21 years of age or older and provided the woman had had no previous children.46 He suggested that the minimum age for marriage should for women be raised from 15 to 18.47 Both measures would encourage later marriage and reduce the period available for child-bearing. At the same time Mauritian doctors should be induced to work in Mauritius. Here again the Welfare State could help. Student grants should, Titmuss advised, be awarded increasingly for Mauritians to study in countries like Australia rather than Britain or France, for the simple reason that – Australia then showing a preference for white immigrants – they were less likely to settle permanently in Australia.48 Similarly, a definite quota of scholarships for study abroad should be reserved for women: quite apart from improving career prospects for women, such a stratagem would help to increase the pool of professionals on the island, since women students are more likely than their male counterparts to return home after qualifying.49 In this way, too, social welfare has an active role to play in helping to mould and structure the nature of Mauritian society.

It was because he believed that the ‘integrated community services’ of the modern Welfare State should be active rather than passive that Titmuss opposed those thinkers in Britain and the United States who, he felt, were fighting a rearguard action against collective progress by arguing for the privatisation or reprivatisation of welfare services. His reasoning was that, if the expansion of social services has a positive influence on the national health, then their contraction and their replacement by private provision is bound to have a negative influence. An example is the move ‘to set people free from the conscience of obligation’50 by establishing private markets for blood, eyes, kidneys

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and other human tissues and organs (while still accepting that a market to buy and sell the whole living human being is immoral). This movement is dangerous since a substantial social cost arises whenever voluntary gifts are replaced by commercialism: ‘It is likely that a decline in the spirit of altruism in one sphere of human activities will be accompanied by similar changes in attitudes, motives and relationships in other spheres.’51 Clearly, ‘if dollars or pounds exchange for blood then it may be morally acceptable for a myriad of other human activities and relationships also to exchange for dollars or pounds. Economists may fragment systems and values; other people do not.’52 The observer of the social scene must be sensitised to its dynamic as well as to its static properties. Specifically, he must recognise the fact that an erosion of the sense of community is likely to result from an extension of the role of market transfers in social life: Once man begins to say, as he sees that dollars exchange for blood supplies from Skid Row and a poor and often coloured population of sellers, ‘I need no longer experience (or suffer from) a sense of responsibility (or sin) in not giving to my neighbour’ then the consequences are likely to be socially pervasive. There is nothing permanent about the expression of reciprocity. If the bonds of community giving are broken the result is not a state of value neutralism. The vacuum is likely to be filled by hostility and social conflict.53 The ideologists of free enterprise capitalism tend to neglect the social costs that result from the narrowing of social choices to those alternatives associated with the market mechanism. They tend to obscure the spectrum of potential choices that in fact exists. Such an attitude means that a very large number of economists in practice, and despite their oath of value-neutrality, ‘perform as missionaries in the social welfare field and often give the impression of possessively owning a hot line to God’.54 Although naïve rather than malicious, such libertarians none the less are dangerous once it is recognised that ‘the myth of maximizing economic growth can supplant the growth of social relations’.55 Market economists are insensitive to such relations. The reason is that they are imbued with an outdated methodological individualism, with abstractions lingering on from the nineteenth century and ‘wrapped round the

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concept of individual man acting outside the matrix of his particular society’.56 The possessive individualism of market capitalism is unacceptable in the social-policy field. To begin with, it favours economic growth and neglects other welfare needs and objectives of the social group. Yet increasingly ‘we have begun to recognise that social growth – the need for integration, the need for more equality of opportunity, the need for freedom from want – deserves as much attention, intellectually as well as in terms of political action, as economic growth’.57 Then, too, market-oriented theories stress the bilateral transfer and neglect the ethical superiority of the gift. This is the direct opposite of Titmuss’s own view that altruism in giving to a stranger does not begin and end with blood donations, and that as often as possible people should be put in situations where they can get in the habit of making gifts rather than bargaining contracts. In the last analysis, therefore, social policy is not simply about therapy for the dependent but about how people interact. It ought most of all to focus ‘on processes, transactions and institutions which promote an individual’s sense of identity, participation and community and allow him more freedom of choice for the expression of altruism and which, simultaneously, discourage a sense of individual alienation’.58

Social policy focuses on integration and involvement. So does what Titmuss believed to be socialism: ‘Socialism is about community as well as equality. It is about what we contribute without price to the community and how we act and live as socialists.’59 Socialism is not simply about levelling, about how much of the rich person’s property the poor person can expect to enjoy, for ‘socialism is also about giving’.60 The fact is that the paradigm of good social policy coincides with that of the good society as conceived by the good socialist, and is the stranger-gift in blood donation. Perhaps it is true that the term social policy itself ‘does not imply allegiance to any political party or ideology’.61 It is no less true, however, that social policy as conceived of by Titmuss can hardly be divorced from what he defined to be socialism. Both make a value-judgement stressing integration, redistribution, community and altruism. Both recognise the social significance of individual needs. As Titmuss puts it, ‘socialist social policies are, in my view, totally different in their purposes, philosophy and attitudes to people from Conservative

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social policies. They are (or should be) pre-eminently about equality, freedom and social integration.’62 His comparison between the Labour Party’s National Superannuation Bill (lost in 1970) and the Conservatives’ Social Security Bill led him to conclude that ‘choice in this particular area of social policy is not just a matter of detail – of marginal differences in administrative organisation and social engineering. At bottom, the real choice consists of two fundamental contrasting views of the objectives of social policy and different interpretations of the nature of man.’63 Here, as always, choice involves ideology and values. Here, as always, Titmuss makes clear where his own sympathies lie. Titmuss believed that man must continue to ‘reach out for the politically impossible’, and ought not simply to ‘busy himself with the resurrection of utilitarian theory’ or (no less deplorable) to ‘cultivate the new stoicism of affluence’.64 He had reason, moreover, to be optimistic about the future. By opting in Titmuss’s own time for the new Welfare State, the electorate had made a value-judgement in favour of social justice and the community. In such circumstances a socialist might truly be tempted to conclude that what is is rapidly becoming what ought to be.

3 Some Methodological Considerations

Social policy exists in a social context. Social scientists have a unique opportunity to be of service to the group. Hence the methodological importance of four interrelated concepts: generalism, humanism, relevance and scepticism.

First, generalism. Titmuss believed that ‘the study of social policy cannot be isolated from the study of society as a whole in all its varied social, economic and political aspects’.1 In discussing social policy, it is not possible to abstract from the complex changes taking place in a complex society (changes, for example, in population, the position of women, the family, social stratification, race, mobility, urbanisation, industrialisation, the work ethic). Nor is it sensible to brush aside the multiplicity of human needs, which make any policy discussion many-sided, multidisciplinary and interdisciplinary. The discipline of Social Policy and Administration ‘does not claim to be a distinctive, separate discipline’2 or a ‘self-contained specialism’.3 Rather, it is dependent on ‘the methods, techniques and insights of the historian, the economist, the statistician, the sociologist or, on occasion, some of the perspectives of the philosopher’.4 Indeed, the subject is ‘the concern of all who live in an industrial, urban country’.5 The discipline itself has an integrative function. Infringing ‘the unwritten rules of academic trespass’,6 it is able as a result to offer the ‘imaginative excitements of unifying perspectives and principles’.7 The student of social policy must therefore be sensitised both to the fact that social policy exists in the broader context of society itself and to the complexity of human beings. Unfortunately, the 43

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extensive and often excessive division of labour in scientific research is a force operating in the opposite direction. Nowadays, Titmuss wrote, many social scientists are no longer able to see the whole human being: ‘Industrial psychologists and sociologists . . . seem to be falling into much the same trap as some economists. Hence they observe only a part and a steadily smaller part of man’s life in highly industrialized societies.’8 It is a sad fact that professionals (including the ‘less gifted and less perceptive research worker’9) do like to retreat to some small allotment of skill and specialised knowledge where they feel secure. It also consolidates their social status if their role and function are clearly defined and well known. It should not be forgotten, Titmuss said, that ‘professional people, whether they be doctors, social workers or teachers, are pre-eminently people with status problems’.10 Nowadays, ‘most professions . . . may sometimes be regarded as associations for spreading the gospel of self-importance’.11 Excessive compartmentalism is an occupational hazard of excessive professionalism. In the socialpolicy field at least, the specialist must overcome his fear of trespass and recognise the need to be to some extent a generalist.

Second, humanism. One of the reasons why Titmuss so strongly advocated generalism was his belief that a citizen must be seen in his fullness and richness, as an actor who plays many parts (a worker perhaps, but also a father or a mother, a member of a community, and so on). He believed that narrow scientism and the tendency to regard people as numbers in a table was the enemy of humanism. He warned of the danger ‘that concern for the value and uniqueness of the individual human being may be diminished if the scientific outlook spreads to embrace more and more of human affairs’.12 Titmuss recognised that statistical tools are a considerable help to the scholar as they enable the investigator to recreate human situations. He made a point, however, of looking behind the figures in order to reconstruct the real individuals who were hidden there. The following discussion of why a mother might have wanted to return from wartime evacuation to the dangers of an urban community is a good illustration of his tendency to personalise and of his sensitivity to real people: There were the savings clubs and the sickness associations which bound contributors to a particular voluntary hospital or firm of

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doctors; the well-known school treatment clinic or ‘welfare’ where you could get different forms of help from people who understood your trouble; the friendly society, insurance agent or co-operative, upon one of which you were relying for a small sum to buy new blankets or an extra bed; the medical officer to whom you could look for cod-liver oil for the baby, or advice about Mary’s ear trouble; the health visitor – an old friend – who had done so much when Jimmy was ill and had seen him grow up and leave school; the midwife who had made arrangements for a friend to look after Jane when the last baby arrived; the lady at the Charity Organisation Society who had helped when father had all his teeth out; the school nurse, the teacher, the lady at the hospital, the assistance man and, finally, the serried ranks of check traders, secondhand dealers, hire-purchase firms and club roundsmen. These were the people who were known, liked, disliked or tolerated. They fitted into a part of life that had meaning. They were the people who helped to stop the leaks, who patched and repaired and encouraged in the cycle of birth, marriage, illness, death and all the ‘rude inelegance of poverty’.13 In this passage Titmuss demonstrates (apart from his evident admiration for the seamless web of the working-class community) a novelist’s capacity to write lyrical prose coupled with a novelist’s ability to get inside the minds of other people. Nor is this passage an isolated instance. As another example of his ability to empathise with people’s detailed perceptions of their own lives, consider his discussion of those unfortunate city-dwellers who ‘trekked’ in wartime from the towns in order to spend each night in the country: The fact that many people chose to trudge off into the country each evening did not, by itself, imply a deterioration in morale. These people were afraid of the bombs; of dark hours of wakefulness, of listening, sometimes tense and sometimes nodding, for the drawn-out whine, and then the rumbling murmur of a house collapsing in the blackness. Above all, they wanted sleep; for sleep was forgetfulness and rest.14 Such passages must not be written off as obiter dictum sentimentality. They show that real understanding of the human condition which Titmuss envisaged as an essential complement to statistical tabulation.

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Third, relevance. Social policy has the power both to observe facts and to create them, but the social scientist ought not to prescribe ends for the community and should accept the values it evolves. The scientist can attempt to persuade the community that its aims are incompatible or even undesirable. Academia, however, must in the last analysis accept that there is a premium on social relevance and that the search for knowledge must be in the service of society. Because of his stress on relevance, Titmuss had occasion to warn the universities that they ought not to be ‘abstracted from society and wholly unresponsive to the needs of their times’:15 ‘No university can be free to establish, say, a faculty of veterinary medicine; to buy as many computers as it thinks fit; to concentrate its resources on teaching students from other countries; or to ignore completely the needs of society.’16 Titmuss reminded the universities that they are financed by the group and must show ‘responsiveness to the welfare objectives of that society’.17 They must meet ‘the trained manpower needs of their age’18 and plan ahead to ensure that their nation will have adequate trained personnel with requisite skills at some date in the future. They must not forget that their obligation is ‘to serve the needs of others and society at large’19 as well as to attend to the aspirations of their staff. The output of a university comprises the twin products of teaching and research. In the case of teaching, a student’s education ought to embody both ‘practical usefulness’ and ‘intellectual excitement’.20 This means, on the one hand, that education ought to help students to acquire specific skills and prepare for a socially useful career: there is a need, as Titmuss puts it, ‘for education which furthers the abilities of men and women to reason and act effectively in a variety of vocational situations’. 21 It also means, on the other hand, that education ought to help students to think independently. While rejecting as élitist the claim that ‘learning to think’ is an end in itself, and while insisting that people must be able to act as well as reflect, Titmuss none the less deplored the promotion through education of excessive specialisation: Consider the growing substitution of specialization for general education. What education for democracy is there in much of the professionalized, sectionalized diet served up today to students in most universities, technical colleges, teachers’ training courses and other places of instruction? Are we not, indeed, witnessing a triumph of technique over purpose? What, in fact, are we

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offering to a majority of the young beside material success, the social graces, vocational techniques and, in particular, professional salvation?22 Titmuss rejected cost–benefit studies made of the effects of education on the grounds that a high rate of return on investment in training might reflect precisely that economic progress which is purchased at the cost of social growth: ‘The current obsession which sees education as capital investment for the purpose of “keeping up in the economic race” suggests that our values are being distorted.’23 He also warned against excessive credentialism, ‘the ultimate absurdity of which might be that no public gardener would be allowed to grow roses without a Ph.D. in Horticulture’.24 In the social policy field, education can play a vital role in helping to train humane and enlightened social workers and other personnel, and to challenge knee-jerk attitudes and conventions which impede an improvement in service. Such improvement is not just a question of quantity of resources. It is also a question of quality of staff: We know now from experience in Britain that we did not abolish the spirit of the old and hated poor law by enacting new legislation in 1948. The same people – the same administrators and workers – still had to run the hospitals, public assistance offices and welfare services. They poured into the new social service bottles the old wine of discrimination and prejudice.25 The second product of the university is research. It too should be relevant to the needs of society. Research must be the servant, not the master, and must be aimed at helping people to acquire better control over their environment so that they have more freedom to develop their personality. Again, personal contact of students with lecturers is, like personal contact of patients with doctors, vital to prevent alienation; and hence lecturers should avoid a flight into research where it means the neglect of teaching. Combining these two points, it would be true to say that a lecturer who does research on non-relevant subjects and simultaneously treats his teaching as a burden is attempting to secure his individual self-advancement at the expense of the group. In the domain of social policy, research has the important social function of helping the community to get at the facts of the social

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situation. In that way it enables the society to make intelligent choices on the basis of hard evidence rather than in that intellectual darkness where myth and prejudice thrive. Titmuss had ‘a strong belief that one of the purposes of the university in the modern world is to help society to make informed political choices about economic growth, about social growth and about educational growth’.26 Seeking the facts, the scholar is also serving his nation. Hence the academic should recognise that his primary duty is to the truth, not to professional success nor even to political ideology. He cannot, of course, escape his ideology, but he ought at least to indicate where his evidence stops and his bias begins: Our first and last duty is to the truth. It is because I am sceptical of the claims that are sometimes made for a value-free social science that I restate this fundamental allegiance. The values that we hold should be clear to our students; the evidence on all sides should also be clear. It is part of our responsibilities to expose more clearly the value choices that confront societies in the arena of social welfare.27 Social policies are likely to be more effective if they are ‘grounded in a basis of fact about reality’;28 and clearly, ‘social diagnosis is needed as well as individual therapy’.29 If the dependent are to be helped, they must first be identified and information about their condition must be made available to policy-makers. Similarly, any action to deal with the distribution of income and wealth or the burden on the health services is more likely to succeed if assertions can be avoided which ‘do not rest on any firm basis of fact’.30 The Welfare State has not always benefited most those whose needs are the greatest. Part of the reason has been inadequate comprehension of user-patterns and latent wants: ‘Only now are we coming to see that we need much sharper tools of social study and measurement; more precise social analysis of conditions, needs and the actual functioning of services; more attempts at social planning in alliance with economic planning.’31 In short, research in social policy, like teaching, has a dual function. It is enlightening and even exhilarating in its own right in so far as it advances ‘our knowledge of human behaviour in situations of change’.32 It is socially useful in so far as it is instrumental in bringing about a change in situations. Social policies must be formulated on the basis of observations and forecasts. Titmuss was understandably critical of the lack of

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intellectual preparedness in Britain on the eve of the Second World War: No Cabinet committee maintained a continuous watch over the social services. No research was conducted into the effects of bombing on the apparatus of civilian life. No comprehensive study was made of the social consequences that might flow from the kind of war that the Government expected. Inadequate factual knowledge and an inadequate endeavour to acquire it, a deep ignorance of social relationships and a shallow interest in social research – these things were later to handicap the work of Government Departments.33 Fourth, scepticism. Titmuss believed, as has been seen, that the facts are, regardless of one’s value-orientation, the prerequisite for reasoned argument. He warned that ‘if English social history is any guide, confusion has often been the mother of complacency’.34 He also believed, however, that the academic should recognise the limits put upon his evidence by the unavoidable truth that in the human sciences not all variables are measurable, even through proxies and indicators. The fact is that the world of social welfare does not usually lend itself to precise quantification: ‘We cannot easily measure the effects of particular delivery systems in the satisfaction of education, medical care, child guidance, adoption procedures, cash transfer payments and so forth.’35 It is difficult to compare the value of two years of nursery education to a three-year-old child with the benefit accruing from two years of postgraduate education to a student reading for a Ph.D.; or to know what money value to assign to a human life saved in hospital; or to estimate the costs of urban slums in terms of resentment and bitterness, racial tension and felt discrimination; or to know the extent to which altruism, by diminishing alienation, reduces the incidence of dishonesty and violence in social life; or to calculate the distress caused by the maiming, death or mental breakdown of a loved one in time of war. In general terms, we may conclude that there are few quantifiable indices of costs and benefits basically qualitative in nature: There are few criteria of success (though there are negative ones in the form of failure) in assessing the performance of social service systems. What is, for example, success for the Director of

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a Social Services Department, the Manager of a Supplementary Benefits or public assistance office, a general practitioner, a probation officer, a hostel manager for homeless people or discharged manic depressives?36 In such cases success indicators may be impossible to calculate and society may have no choice but to rely on the informed assessment and professional ethic of people who are expert in the field. Value-judgements are inescapable, crude fact-gathering therefore insufficient. Success in making husbands pay maintenance to wives, for example, could mean a data-bank society and with it the failure to preserve individual privacy. There is no scientific means of ascertaining whether the transfers would outweigh the invasiveness.37 Again, while universities ought as recipients of social funds to be cost-conscious, they ought also to recognise that their objectives are social as well as economic. They are for that reason obliged to reject the ‘narrow world of the accountant or the sillier notions of “productivity” as applied to higher education’.38 In the last analysis, ‘human welfare is an ethical concept’.39 In any case, a study of success and failure in social policy would be a complex exercise were it to take into account (as it should) all present and future social costs and benefits by using a generalised sociological approach. It would be necessary to know, for instance, the percentage of the cost of a patient’s stay in hospital that should be assigned to teaching and research done on him (and thus what economic ‘price’ should be the doctor’s imputed payment to the patient for the right to use him as an input); or the opportunity cost of the voluntary blood donor’s time (remembering that the data are not precise: ‘For women donors the value of housewives’ services cannot be measured’40); or the specific value of the integration and altruism that are engendered over time by universalism in place of the market. The difficulties imposed by the temporal factor should not be underestimated. A mental patient discharged may represent success for the mental hospital (since the client is then ‘off the books’), but this success may also mean the demand for a place in a hostel for the single homeless, for unemployment benefits, possibly even for police services, prisons and research to explain a subsequent increase in crime. Here, when the case is followed up, it becomes apparent that a narrow cost–benefit study of the hospital alone would ignore many highly relevant costs and

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benefits throughout society. It also becomes apparent that a broader cost–benefit study would be virtually impossible to carry out. It is significant that Titmuss makes no attempt to use such an approach in his study of blood-banking systems. The social scientist must face the fact that much of the knowledge of how socialised beings live together in groups is vague, imprecise, impressionistic, collected in situational contexts which are themselves diverse, intricate and changing. The student of social policy must recognise that the mechanistic method (involving ‘a questionnaire, a random sample of delinquents, and a computer’41) is not a substitute for the test of the intellect; and that the field of social policy offers no quantifiable indices comparable to the engineer’s measurement of efficiency or the economist’s estimation of managerial success in terms of profits. The student of social policy must come to see that, compared with the more prestigious natural sciences, we cannot so easily measure the complex sicknesses of a complex society; the prevalence of the stress diseases of modern civilization, the instabilities of family relationships or the extent of mental ill-health in the community. Difficulties of accurate measurement should not prevent us, however, from seeking to extend our knowledge of the causes at work.42

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4 Part One: Evaluations and Extensions

Social policy is concerned with social values and collectively defined needs. The consensus is at once the conservative consequence of past occurrences and the radical cause of future departures. Welfare policies vary with ideology in time and space rather than converging to equilibrium along a unique developmental trajectory. Privatisation would threaten the self-perpetuating community by legitimating the divisiveness of the Hobbesian bellum. Socialism would reinforce the bonds of belonging by putting in place integrative institutions which reaffirm the common and the shared. The social scientist, a social actor like his fellows, cannot afford to neglect the methodological importance of multidisciplinarity, understanding, a sensitivity to social purpose and an acceptance that there are limits beyond which the statistics will never go. What it all adds up to is this, that ‘social administration as a subject is not a messy conglomeration of the technical ad hoc’1 but instead a focus for the ‘imaginative excitements of unifying perspectives and principles’.2 The driving force is the overlapping ethic. The embedding context is the interdependent matrix. On the one hand there is the pursuit of the ideal. On the other hand there is the preservation of the organic. It is the task of this chapter to evaluate Titmuss’s vision of the status of social policy and to explore the ways in which it might be extended to meet the needs of a world that Titmuss never knew. Titmuss would have welcomed the search, arguing as he always did that to fossilise an answer is to deprive it of sense: Choices have continually to be made in the modern democratic state. We cannot make them for all time – either about the kind of services people need or the ways in which services are organised, administered 52

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and paid for. Continually to rely on the solutions of yesterday – whether they were reached through the accidents and the forces of history or by the deliberate decisions of men – is eventually to leave society without a sense of social direction. Nor can it be found by forgetting the past in a single-minded search for more material wealth.3 Social policy must move on if it is not to be left behind. Whether Titmuss would have been in broad agreement with the precise evaluations, with the specific extensions that form the subject of the two sections of this chapter can, needless to say, only be a matter for conjecture and debate.

(a) The sub-division of welfare Titmuss states that human blood is not a ‘trading commodity, a market good like aspirins or cars’, but rather a ‘service rendered by the community for the community’.4 The still photograph of the British status quo is clear enough. The analytical dividing-line between trading commodities like aspirins and cars in the one lane, community-confirming services like blood for transfusions in the other is, however, more of a problem. It is never easy to prescribe just how much social policy a responsibly mixed economy ought to select, just how much private enterprise it ought to include in its portfolio. Concerned that is-ness is being left de facto the sole test of ought-ness by a democratic consensualist reluctant to take a lead, the reader may object that Titmuss’s theories provide insufficient guidance as to the proper location of the boundary between the freely given and the paid-for through exchange. Titmuss consistently stressed the need for clarity – for a cast-iron grip on ‘the rationale of the social services; the roles they are playing in society, and the ends to which, separately and in combination, they are directed’.5 As an empiricist who was also a philosopher, he believed that phenomena had evolved so rapidly in the area of social policy that conceptualisation and understanding had regrettably been left behind: The social services are the product of the 20th century and the rapidity of their development has not been accompanied by a parallel development in theoretical analysis . . . Most of the textbooks on the subject are confined to straightforward, descriptive accounts of organisation and statutory provision.6

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Titmuss knew that there was an explanation gap in the subject area. Importantly, he also went out of his way to say that there were limits to what he could do. The reader who objects that Titmuss is excessively vague as to the ideal boundary between the welfare sector and the market should be reminded that Titmuss himself experienced a similar frustration at being unable to identify the precise boundaries of his camp. Thus Titmuss in 1967 was telling Greeks that his was an ‘immense field . . . Definition like beauty . . . what is and what is not a Social Service? A political definition, a sociological definition, or an economic one?’7 In 1964 he was informing Israelis that he was not in a position to name the optimum: ‘I am no expert. Welfare is concerned with social values and human relations. It may be the embodiment, carrier and expression of a philosophy of everyman’s place in society. There is no authoritarian role here for the expert.’8 In the 1950s he was admitting to Scots that only a decade after Beveridge he was already without a compass: ‘I come to tell you that the maps most of us use are out-of-date; that Beveridge is a better guide to the 1930s than the 1950s; and that the social service world, as a separate, autonomous entity, does not exist.’9 Titmuss knew that the precondition for the study of the caring sector was an unambiguous specification of what the black box contained. He also knew that he himself could not supply the checklist that was so much in demand. A lecture from the 1950s – its sub-title is ‘An Essay in Confusion’ – reveals his own frustration at being forced to start from here when the here in question had for him no intrinsic appeal: ‘Even a superficial analysis will show that it is almost accidental whether a particular need, when met, is or is not regarded as a social service.’10 The Health Service is in. Marriage guidance is out. School meals are subsidised welfare. Works canteens are a fringe benefit. Shakespeare read in a classroom is the gift relationship. Shakespeare seen in a theatre is a commercial transaction. Titmuss was sharply critical of the complacent conventionalism that made yesterday’s accidents into today’s ‘done thing’ in cases such as these: ‘There is little that is rational about this classification.’11 Titmuss made a diagnosis of an inescapable ‘confusion which surrounds the concept of what constitutes a social service’.12 Valuable as is the way in which he elucidated the categories (by showing, say, that private pensions in common with state pensions are in receipt of fiscal support), the fact remains that Titmuss, aware as he was of the

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boundary-line problem, was in the last analysis unprepared to be precise about the activities that belong to sharing, the activities that can be delegated to Mammon with some benefit.

The ambiguity is a source of especial difficulty in the case of those goods and services which are actively in supply on both sides of the public–private divide. Human blood must be procured and distributed on a community-confirming basis if it is not to pass on the stranger gifts of hepatitis and conflict. Aspirins and cars are satisfactorily supplied through profit-seeking capitalism that requires neither nationalisation nor planning to deliver with efficiency. The either/ors are clear enough. What is less clear in Titmuss’s work is the legitimacy of coexisting provision in areas such as health, education and insurance where both welfare and exchange had a significant presence. Titmuss was in favour of equality of opportunity and community of experience. He also believed that state services performed better than commercial in mixed industries where direct comparisons could be made. For those two reasons one would have expected him to recommend the suppression of crude economism and market competition in those welfare activities which had ill-advisedly settled where they did not belong. One would have been wrong. Titmuss defended the availability of pay beds in state hospitals and the existence of a parallel system of private medicine. In respect of the educational head start, he knew what the public schools meant in terms of facilities and contacts but only once directly recommended their incorporation into the state system. That uncharacteristic call to end the mixed educational economy was made in the Introduction Titmuss wrote for the 1964 reprint of Tawney’s Equality. The demand was not repeated. Titmuss had nothing to say about the nationalisation of the British pharmaceutical industry (despite the symbiotic links it maintained and maintains with its dominant customer, the National Health, links so intimate as to recall the American military–industrial complex). Nor did he consider the social ownership of the private insurance corporations (companies seen to be socially divisive to the extent that they perpetuate economic inequalities into states of dependency; and within which, Titmuss believed, non-accountable managers combine maximal power with minimal social responsibility). Tawney had recommended the state ownership of the banking sector

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– ‘for it determines the economic weather more directly than any other’.13 Titmuss was unprepared to prescribe the same medicine for the private insurance corporations – although he was clear in his own mind that private bureaucracies were depriving the nation both of the integration and of the performance that state bureaucracies were in a strong position to deliver. Titmuss advises a pragmatic and open-minded assessment of the options: ‘The alternative to public policies to-day in respect to many social needs for most people is not “free enterprise” . . . The real choice is between one “bigness” and another “bigness”.’14 His assessment completed, Titmuss is then strangely silent on the extent to which the norm of altruism, good business and good moral philosophy in the social welfare sector, should be liberated for progress in the capitalist market economy which retains a high profile in welfare-replicating commodities like insurance. In the case of insurance, Titmuss was at least prepared to advocate greater state regulation. Noting, for example, that insurance companies in five of the original six Common Market countries were obliged by law to invest a substantial part of their funds in government stock, he advised that the British Government take similar measures to compel such loans.15 Otherwise, he accepted that the dual system in insurance (like the dual system in health and education) was to be regarded as a fact of life. Private insurance in that way acquired the status of a ‘trading commodity’ (on the model of aspirins and cars) – while state insurance, of course, remained resolutely a ‘service rendered by the community for the community’ (as if blood donated to help unnamed strangers or aid to poorer countries under threat from a drought). Yet insurance is insurance, just as blood is blood. Titmuss’s accommodating tolerance in the face of a dual system that was also a dual standard, of Apartheid-like structures that segregated the wealthy from their less prosperous team-mates, would seem to be at variance with the citizenship-based ideal of upgrading ‘from working-class standards to m/c standards’: ‘The objective [is] to abolish two standards of medical care, education, housing, social security and welfare generally.’16 It is possible that Titmuss was too timid – too moderate – in respect of the welfare-replicating sector that was a de facto obstacle to equality and integration. In Titmuss’s defence, however, it must be emphasised that Fabians make haste slowly and that Titmuss saw no need for an instantaneous unification. Titmuss indisputably regarded the state system

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as potentially a comprehensive one, but he also knew that democratic consensus was the sine qua non. A believer in persuasion and choice rather than regimentation and force, he probably reasoned to himself that the separation between public and private would one day be transcended; that the dual system would ultimately become one; and that the key to universality by consent lay in the last analysis in the demonstration effect of that which is not only free and accessible but provides a better service as well. Such an interpretation, filling in the gaps in what Titmuss wrote, is an extension of his model that retains the ideal of the gift of blood as the paradigm for good social policy but also accepts that compromise is necessary if other people (including wealthy people) are to be treated with respect.

Titmuss was always resistant to the term ‘Welfare State’ – ‘Do not know what it means’17 is a characteristic reaction – but appears to have defined it as the embodiment of two interrelated aspirations, two sets of objectives which together point unreservedly to ‘an enlargement of social responsibility’.18 The first element is well represented in his published books and articles. The second element, regrettably, is discussed only in unpublished lectures and notes. The consequence of the imbalance is a failure to appreciate the significance of what might be called ‘macroeconomic welfare’ in the socio-economic system of Richard Titmuss. The first of the two elements is the familiar objective of inclusion and levelling up, ‘the transformation in aims of limited, public assistance social policies to comprehensive, citizenship policies’.19 Thence come the services in kind of housing and social work, together with the well-financed empowerment that makes a reality of ‘equal opportunities to education and health’.20 Thence come the payments in cash that make child benefits, disability allowances and old-age pensions a means of affirming ‘collective responsibility for minimum subsistence for all citizens . . . in times of adversity and non-earning’.21 Titmuss was perceptive enough to recognise that alongside state welfare there existed the parallel systems of occupational welfare (an example would be company pensions) and fiscal welfare (consider tax relief for mortgage interest) that satisfied the same need for society’s most fundamental services. The second of the two elements makes the ‘Welfare State’ quite explicitly a macroeconomic State in the sense that the government

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is obliged to take upon itself the ‘Collective responsibility for Full Employment. The Right to Work. Control and Supervision of the economy. The Keynesian Revolution. The avoidance of mass unemployment.’ 22 Titmuss said that it was one of the defining characteristics of the commitment to welfare that there would have to be ‘a more positive policy of State management of the economy – adoption of full employment as a policy – deliberate selection of priorities (housing before cinemas, etc.) – and a greater use of fiscal, monetary and physical instruments to achieve certain ends’.23 Titmuss’s published work gives the impression that he took full employment as background economics and not as a topic in social policy. Titmuss’s unpublished work demonstrates that for him an interventionist macroeconomics could be a characteristic of the ‘Welfare State’ too. Keynes in the General Theory had in 1936 continued his earlier theme of ‘The End of Laissez-Faire’ by arguing strongly that market homeostasis could not be relied upon either to ensure fair shares or to eliminate excess capacity: ‘The outstanding faults of the economic society in which we live are its failure to provide for full employment and its arbitrary and inequitable distribution of wealth and incomes.’24 The duality of Keynes’s critique of the invisible hand – social injustice combined with macroeconomic slack – looks forward not just to Titmuss on the ‘Welfare State’ but also to Beveridge and the reforming Liberalism that Titmuss had imbibed in Hendon before he came into contact with the Webbs. Thus Beveridge in the mould-making White Paper of 1942 had made the management of total demand a necessary condition for the relief of residual dependency: ‘A satisfactory scheme of social insurance assumes the maintenance of employment and the prevention of mass unemployment.’25 Social Insurance and Allied Services identifies a warfare State under threat from five ‘giants’. Four of those giants (Want, Disease, Ignorance and Squalor) can be neutralised by means of Titmuss-type social service policies. The fifth, however, is Idleness – a waste of human resources ‘which destroys wealth and corrupts men’26 – and here Beveridge argued that nothing short of a discretionary macroeconomics would be sufficient to correct the twin deficiencies of resourcing and of self-respect: The economic problem is that of doing deliberately in peace that which we are forced to do in war – of creating a community in which men and women have value . . . If full employment is to be

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attained, the target for peace must be such as to set up effective demand for the products of labour constantly exceeding the supply.27 Beveridge, like Keynes, looked to the visible hand both for equity in the balance of endstates and for the opportunity to earn life without which income maintenance, however generous, must still stigmatise and shame: ‘Bread and health are not all that a citizen needs. Idleness even with bread demoralizes.’28 Titmuss, like Beveridge, looked to the ‘Welfare State’ for the prudent demand management that married the right to a social wage to the right to a decent job. Writing after 1944 (when Cmd. 6527 on Employment Policy made a promise that the defeat of the Germans would not be the victory of the dole), writing after 1948 (when full employment was established and underemployment equilibrium crowded out by Beveridge’s utopia of ‘more vacant jobs than unemployed men’29), dying before 1976 (when James Callaghan reassured the International Monetary Fund that price inflation would be contained even if marginal labour had to manage without work), dying before 1979 (when Thatcherite monetarism, accusing welfarism of pushing up the ‘natural rate’, called for supply-side economics to price people back into jobs), Titmuss presumably saw little need to state the obvious or reiterate the accepted in respect of Keynesian macroeconomics as an element in the ‘Welfare State’. That he was prepared where necessary to stand on the shoulders of giants is, however, absolutely clear, if clear almost entirely from his unpublished lectures and hardly at all from his books. Thus Titmuss, speaking in Copenhagen on the British experience of social growth, stated without reservation that it was macroeconomic welfare that had done most to deliver the gains: ‘Improved health, better nutrition, lessening of class consciousness, the reduction of gross poverty, fewer inequalities – owe more to Full Employment than anything else or all the Social Services.’30 Addressing the British Council in London, he made the same point about paid employment and the social revolution: ‘The greatest change since 1939. Full employment. The right to work fulfilled. Cannot emphasise this and its social implications too much.’31 The State’s guarantee of a high level of demand meant not the Marxian reserve army, hungry and anxious, but rather a Smith-like competition on the part of employers to attract and retain. Seen from the perspective of the less advantaged, Titmuss left no doubt, in the notes he made for the British Council talk, that ceiling operation was a fundamental cause of welfare:

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‘Security and regularity of income – effects on living standards – more families able to plan ahead. Most important consequence: health and vitality of children – more important than social services.’32 Titmuss is not saying that Keynesianism is a substitute for casework, income support or the Health Service. What he is saying is that the guarantee of a tight market for labour has proved more beneficial in total than have the welfare institutions created since Attlee to relieve distress: Full employment has done more than any or all of these services not only to raise standards of living but to give millions of people a greater sense of self-respect and independence. But of course these social services have contributed – they have had some effects (difficult as they are to measure) on health, productivity, standards of education, family life and other patterns of behaviour in British society.33 That statement, taken from a BBC talk in July 1958 to mark the tenth anniversary of the NHS, is a useful reminder that for Titmuss the ‘Welfare State’ went beyond the caring services to bring in macroeconomic welfare as well.

Macroeconomic welfare is an integral part of the system. Microeconomic welfare, on the other hand, is a domain that Titmuss seldom if ever chose to visit. The omission is a curious one. The market economist will defend laissez-faire with arguments relating to allocational and dynamic efficiency. The classical liberal will see in supply and demand the free and spontaneous contracting of discrete individuals with unique preference patterns. Thinkers whose maximand is growth or autonomy will understandably resist any attempt to make the regulation of business activity a topic in social policy. Titmuss, however, was a consensualist and a welfarist, a man of principle whose priority was not affluence or initiative but instead ‘a more civilized, humane and compassionate society . . . a fairer distribution of wealth and command-over-resources . . . higher standards of social justice for the under-privileged and deprived; more generous treatment for the victims of social change’.34 Given that aid to others ranks so highly in his pantheon of values, it is a curious omission indeed that economic organisations, whether as sellers or as employers, are not to be invited to provide

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microeconomic welfare in acknowledgement of the citizen’s contract with the All. William Temple, with Zimmern in 1934 and Schuster in 1937 among the first (in 1941) to speak of a ‘Welfare State’, wrote eloquently in the year of Beveridge about the need to make the economy the servant and not the master of the ethical and the just: We all recognize that in fact the exploitation of the poor, especially of workhouse children, in the early days of power-factories was an abomination not to be excused by any economic advantage thereby secured; but we fail to recognize that such an admission in a particular instance carries with it the principle that economics are properly subject to a non-economic criterion.35 The Archbishop of Canterbury had learned well the lesson preached by his Rugby contemporary, Tawney: ‘The individual has no absolute rights: they are relative to the function which he performs in the community of which he is a member.’36 Temple and Tawney had no reservations about the sensible deployment of microeconomic welfare such as might serve for particular groups of potential dependants the same function as the macrosocial services. Titmuss chose not to emulate their quasi-Keynesian interventionism. Had he wished to do so, however, there is much he could have prescribed for organisations, both as sellers and employers. The price of goods has an obvious impact on consumers’ wellbeing. Income support and shopping vouchers are the social-welfare response to real wages made intolerably low by the high cost of necessities. Positive as their contribution may be to the enhanced market power of the targeted buyer, it must not be forgotten that state inducements and state directives can fulfil precisely the same value-driven function of bending the buyer–seller relationship to the dictates of a social consensus that will not allow outcomes to lie where they fall. The fact that microeconomic welfare assists the buyer through action taken specifically to circumscribe the seller must inevitably make it especially attractive to the interventionist who is not just a reformer but a socialist as well. Taxes and subsidies are the policy instruments recommended by the middle-ground economists Marshall and Pigou when they address the problem of social benefits underproduced by an uninstructed interest. Applied to the price of goods, what this could mean is the exemption from indirect taxation of welfare commodities like

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children’s clothing and basic foodstuffs, the subsidisation on a generous scale of vital infrastructure like public transport, fuel and water. Taxes and subsidies have the attraction to the middle-ground mind that they work through demand and supply rather than requiring the suppression through directive of the gain-seeking mechanism itself. Although Titmuss does not say so, it is probable that microeconomic welfare proceeding by means of fiscal inducements such as these can be incorporated without difficulty into the familiar category of fiscal welfare which Titmuss normally reserves for social-service cases alone. There would not seem to be a world of difference between tax reliefs for the purchase of private health insurance, tax holidays for the construction of low-cost housing (a targeted benefit on the model of cold-weather payments) or even public subsidies for the conversion to lead-free petrol and the fluoridation of domestic drinking water (a universalist benefit which, like the NHS itself, is available to all classes on the sole basis of personal need). Directives to control the price of goods are more difficult to situate within the framework of Titmuss’s established categories. A ceiling price for nutritional staples is a way of ensuring that the shopkeepers do not pocket the windfalls of a famine. A usury law may restrict the supply of savings but at least it keeps the money-lenders at bay. The lessons of the medieval ‘just price’ and of Aquinas on the ethically informed economy look forward not only to Papal Encyclicals like Rerum Novarum in 1891 and Quadrogesimo Anno in 1931 but also to rent control in Titmuss’s own Britain which, it may safely be assumed, Titmuss saw no need to replace with ‘whatever the traffic will bear’. In that case at least, he is likely to have implied not only the legitimacy of directives but also the possibility that the controlled market could have the function of welfare. Inducements and directives subordinate the organisation to the collectivity in respect of the sale of output. Microeconomics constrained is, conceptually speaking, no less a source of welfare enhanced in the case of the employment of labour. Socialist authors like Owen and Marx had made economic exploitation the irreducible cause of social disharmony. Union leaders in the Britain of ‘you’ve never had it so good’ had not hesitated to use the strike weapon because Henry Dubb had been cost-benefited as input and deeply resented the slight. Market remuneration unacceptable, the market mechanism divisive – there is a tradition in British socialism which says with Tawney ‘One can’t look a gift cherub in the mouth’37 and

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which is deeply sceptical of any labour contract save one which embeds the economics in a surrounding package of welfare. A tax on labour-saving technology is an inducement to businesses not to drive out semi-skilled workers who would in consequence become dependent on benefits. A subsidy to an ailing giant in a development area is a guarantor of jobs, homes, traditional communities, informal networks that would all be put at risk by mobility forced upon labour by the bankruptcy of a dominant employer. A national minimum wage (rescuing the low-paid from the stigma of means-tested income supplementation) transfers to the firm from the State the economic burden of the poor-in-work. A statutory apprentice scheme requires employers to provide on-the-job training for manpower that would otherwise have been an external economy from the schools. Works clinics and health and safety regulations give businesses a statutory involvement in preventive and curative medicine that would otherwise have been passed to a Welfare State prepared non-judgementally to pick up the pieces of shattered people. Equal opportunity laws and counter-discriminatory quotas might integrate women and blacks at work to at least the same extent as the mental hospital (reinforced in due course by the Supplementary Benefits Commission) integrates them through the comprehensive school of social welfare once their professional frustration has taken its toll. Incomes policies flatten the pay pyramid to the benefit of the lower-paid, contain inflation which is itself a cause of poverty for pensioners on fixed incomes, and obviate the need for deflations and austerity measures that would cause the expendable to lose their jobs. It will be the task of Chapter 15 to consider the social dysfunctionalities and the economic costs that tariff walls, part-timers’ rights and mid-career leaves can represent. The present task is simply to show that microeconomic welfare, conceptually speaking, is as much a part of the welfare complex as are social welfare, fiscal welfare, and occupational welfare, on which Titmuss prefers to concentrate his attention. Accompanying his division of ‘all collective interventions to meet certain needs of the individual and/or to serve the wider interests of society’ into the ‘three major categories of welfare’ with which his name is associated, Titmuss offers the following specification of the realm: ‘The definition, for most purposes, of what is a “social service” should take its stand on aims; not on the administrative methods and institutional devices employed to achieve them.’38 There is no obvious reason why microeconomic welfare should be excluded

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from such a specification, built as it is around functional equivalence and not around legalistic convention. The fact remains, however, that Titmuss himself preferred to treat microeconomic welfare as something outside and beyond. His study was the dependent. It was not the world of work before the victims became a charge upon the State. There is a final point to make about regulation. It concerns deregulation. Titmuss followed Mill, as Tawney had done, in stressing the importance of the open road as well as the equal start. Lecture notes dating from 1954 show that he associated personal fulfilment with freedom from as well as with the gift relationship when a nation moves into modernity: The family more mixed up with society, more dependent on what society has to offer in terms of education, work, social relations and so forth. If these are blocked by restrictions, closed shops of all kinds, class privileges and professional in-breeding then social frustration is bound to accumulate.39 Eton and the old-boy network put up barriers against an able interloper like Titmuss himself. So too, by inference, do union constraints, outdated demarcations, seniority rules and professional bodies that ration access to supra-normal remuneration to the detriment of new entry that cannot pay for the obstacle course. It would in the circumstances make sense to include in the broad category of microeconomic welfare the anti-monopoly policies that are needed to keep the private sector competitive and open.

Titmuss, in a letter written in 1959, acknowledges the ongoing importance of the voluntary bodies: ‘The modern state needs, in addition to collective public services, a variety and diffusion of genuine voluntary agencies.’40 It is a recognition of voluntarism and the gift of labour which is no more than one would expect from a committed communitarian. Titmuss’s ideal was not the passivity of mealtimes in the workhouse but rather the activity of parents who donate children, voters who donate taxes, citizens who donate blood precisely because welfare is as much about St Anthony as it is about the beggar with whom he shared his cloak. Titmuss was a theorist of giving and not just of taking. He was also a welfarist who stated that getting involved was at the cutting edge, that the quid without

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the quo was increasingly a necessity and not merely the icing on the cake: ‘Modern societies now require more rather than less freedom of choice for the expression of altruism in the daily life of all social groups.’41 Given the emphasis on social responsibility and the promise of an outlet for compassion, Titmuss, it might be presumed, would have been quick to have made community-based services, self-help groups, consumer cooperatives and mutual aid societies into a further category – after the social, the occupational and the fiscal, to say nothing of the macroeconomic and the microeconomic – in his taxonomy of care and help. It is a matter of record that he did not do so. Titmuss was a believer in voluntarism and in getting involved. In his publications and in his lectures, however, the duty to others of Toynbee Hall and the willing selfsacrifice of the Charity Organisation Societies are overshadowed into insignificance by the concentrated power of the State. Beveridge in 1948 had warned against the route: ‘The State is or can be master of money, but in a free society it is master of very little else. The making of a good society depends not on the State but on the citizens, acting individually or in free association with one another.’42 Writing when the Welfare State was already a fait accompli, he continued to look back to providential associations like the friendly societies (then already in decline) for the model of mutuality and belonging which he welcomed as a corrective of market failure without the need for top–down shepherding. Economic self-interest, Beveridge warned, is a necessary but not a sufficient condition for social well-being: ‘The business motive is a good servant but a bad master . . . A society which gives itself up to the dominance of the business motive is a bad society. We do not put first things first in putting ourselves first.’43 State intervention, Beveridge continued, must be judged by the same pragmatic standard of benefits and costs. In respect of spending, the State can serve well the nation, both in the field of income maintenance (‘The State alone can ensure that at all times unsatisfied needs are clothed with purchasing power’44) and through its well-informed practice of macroeconomic fine-tuning (‘The State alone, by its management of money, can prevent there being at one and the same time in a community unsatisfied needs, and idle men and machinery by whose employment those needs could be met’45). In respect of commodities and delivery systems, however, the beneficence of the good servant is less easy to establish – and the dominance of the bad master most likely to stifle the autonomy and the dignity

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that, means as well as ends, are the reliable source of the socially sensitive response: In a totalitarian State or in a field already made into a State monopoly, those dissatisfied with the institutions that they find can seek a remedy only by seeking to change the Government of the country. In a free society and a free field they have a different remedy; discontented individuals with new ideas can make a new institution to meet their needs. The field is open to experiment and success or failure; secession is the midwife of invention.46 Beveridge, always more favourable than was his distinguished LSE colleague Hayek to welfarism and to Keynes, had clearly absorbed the lessons both of the road to serfdom that could lead to Hitler and of the information-deficient society that necessitated a decentralised discovery process. Voluntary action could be a part of that process, a corrective of its shortcomings without the need for the State. Beveridge believed that the case for ‘private enterprise, not in business but in the service of mankind, not for gain but under the driving power of social conscience . . . is beyond debate’.47 Reasoning precisely as Titmuss did, Beveridge looked to ‘mankind in brotherhood’,48 to community and to membership, for a stream of returns which ethical capital alone was in a position to produce: ‘There are some things – not goods but services – which often cannot be bought with money, but may be rendered from sense of duty.’49 The scope for gifts agreed, the paths then diverged and diverged quite significantly. Beveridge looked to ‘private enterprise’, solidarity by subscription, philanthropy by consent – to voluntary action, in short – for a valuable empowerment that would allow free individuals to turn their conscience to material as well as to moral advantage: ‘So at last human society may become a friendly society – an Affiliated Order of branches . . . each linked to all the rest by common purpose and by bonds to serve that purpose.’50 Titmuss, on the other hand, was as slow to make the voluntary sector a meaningful part of his theory of welfare as he was quick to recognise in its uncoerced communalism a moral manifestation of good neighbourliness, honest civility and of a fellowship that cares. Titmuss admired voluntarism but had a preference for the State. His relative neglect of intermediate corporations is not an oversight

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but rather a consequence of his logic. Microeconomic welfare can arguably be added on to an existing system. The voluntary sector will be more of a problem. One reason is the nation-building objective. Tawney had assigned a very high priority to the overlap in experience: ‘What a community requires, as the word itself suggests, is a common culture, because, without it, it is not a community at all.’51 Titmuss shared with Tawney the ideal of unifying assumptions, the endstate of Eliza and Higgins integrated into Englishness by a single set of symbols. Voluntarism, like Eton, injects supermarket pluralism into the citizenship fundamentals. Different parent–teacher associations press for different kinds of curriculum. Different medical charities provide different standards of care. On the fringes of welfare, such differentiation is precisely what is needed to cater for a variety of non-standard circumstances: consider the intentionally narrow remit of Alcoholics Anonymous, the ‘school run’, the support group organised by and for chemotherapy patients. At the centre of welfare, however, it is in the nature of the service that without bunching around the mean the product will lose much of the socialising function that so strongly recommends it to the advocate of cohesion. A second reason why Titmuss has so little say about the voluntary sector has to do with the fulfilment of promise. Titmuss, deriving his conviction from the value-consensus, argues that the citizen, where dependent, has a right to his service. Voluntarism, however, is by its very nature discretionary. A charity might lack resources or volunteers. It might ration provision by means of stigma that is at variance with rights. It might opt for second-rate quality that distances Eliza still further from the snobbish Professor. A mutualaid society, again, might turn away the needy who have not paid their contributions. It might refuse to admit as members those citizens likely to impose an abnormal burden. It might undersupply scarce welfare because it is too small for economies of size. Titmuss must have seen that the consumer’s right to welfare must always be a fragile craft where there is not also a producer’s duty to supply. The voluntary sector cannot convincingly take on such an obligation. The state sector can do so. The fact that the nation as a whole shares in the financial commitment offers not just the guarantee of the Exchequer grant but also the knowledge that one citizen is cross-subsidising another within the framework of a club that is as all-encompassing as the national family itself. A third and final reason has to do with the involvement of experts

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and professionals. Peter Townsend has correctly observed that ‘if you have gargantuan departments of state then you are implying that there is some great repository of knowledge about what is good for society in its administration’.52 Pluralism, syndicalism, multiple possibilities have a certain attraction in the open-ended agnosticism of Ivan Illich – in a looking-glass world where teachers impede learning, surgeons cross-infect and where, outcomes aside, ‘any kind of dependence soon turns into an obstacle to autonomous mutual care, coping, adapting, and healing’.53 The gargantuan department of state, on the other hand, is the unhesitating choice of the welldrilled therapist whose professional response it is to select the best possible from the state-of-the-art. In the words of Lord Horder, physician to five monarchs and author of the Preface to Titmuss’s first book: ‘Only the doctor knows what good doctoring is.’54 Titmuss was in the camp of the single right strategy and of the big ministries that universalise the big tasks. Of course he recognised that the well-drilled could end up schooled down to size and blinkered into passive rubber-stamping – he said as much in an LSE lecture in 1965: ‘Expertise has a certain caste-spirit about it, so that experts tend to neglect all the evidence which does not come from those who belong to their own ranks . . . The one thing an expert requires is humility before all the facts.’55 On balance, however, Titmuss was in favour of the expert judgement made a citizenship entitlement through the State. The voluntary sector in that respect simply could not compete.

Social, occupational and fiscal welfare are always to be included in the definition of social policy. Macroeconomic welfare is explicit in the notes and implicit in the publications. Microeconomic welfare may be implicit in the publications and a useful extension to the theory. The voluntary sector is yesterday’s welfare in the theory, an optional add-on but no longer the substance. Ending the list of the welfare-providers is the first – the family. Titmuss, Rose writes, was ‘within the ideology of the family’.56 A sociologist as well as a socialist, he identified in the stable family unit the original welfare pool, the original locus of care, education and support. A disabled child, a convalescent spouse, an aged parent, where cared for in the home, is a burden that does not have to be shouldered by the State. De facto counselling is provided to a relative suffering from stress. De facto nursing is provided to a partner

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whose dressing must be changed. In ways such as these the family supplies the functional equivalent of social services and promotes an overall enhancement in welfare. Were it not to do so – were it to abstain (as in the case of the absentee father or the latch-key mother), were it, still worse, to cause intergenerational harm (consider child abuse or, more subtly, parents ‘unsecure and ambivalent’ who pass on to their offspring ‘a diminished sense of purpose and authority’57) – then the economic and social cost of its dysfunctions would have to be borne by the community. Negatively as well as positively, in short, the family unit is a social fact: ‘For good or ill, the healthy and harmonious working of the family is now the business of society. The failures – as well as the successes – are our concern, for society has decided that it should take care of the individual consequences of such failures.’58 Titmuss believed that the family (nuclear or extended) was the irreducible welfare pool. He also believed that the institution was a social fact that was at once a public concern: ‘We no longer regard family life as being a purely private, possessive affair.’59 Given his description of the family as a semi-socialised undertaking, it is of significance that he did not take the obvious (if also pedantic) next step of making ‘familial welfare’ a sub-system in his social division. It is of significance because it is so indicative of his sensitivity to common usage. Most people regard their loved ones as their own loved ones and not as their nation’s loved ones. To call it ‘familial welfare’ when a parent takes a sick child to the clinic would be as refractory to the median understanding as it would be to speak of ‘individual welfare’ whenever a citizen eats an apple a day, teaches himself a new language or puts money aside in case of chronic ill-health. Titmuss knew that a line would have to be drawn somewhere if the definition of social policy was not to become a tautology or even a joke. In the case of the family, he decided upon a compromise that would satisfy the sociologists without alienating the Dubbs. What Titmuss does is to describe the family de facto as a welfare sub-system but not to give it an official name that would label it as anything other than private. The status of the family requires no more than a clarification. The status of the wife within the family is more of a problem. An unspoken assumption in Titmuss’s theory of welfare provision is that the man is a full-time breadwinner in lifelong employment while the woman adopts the unwaged role of homemaker and domestic carer. Less likely to be a part of the formal, monetised economy,

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she is less likely to have earned income of her own (culminating in an occupational pension in the retirement phase) and more likely to be dependent on her partner for (largely discretionary) support. Titmuss does not question this gendered division of labour. Nor does he reflect critically on the extent to which the Welfare State itself enjoys a hidden subsidy from low-cost carers such as nurses and social workers. Tacit is the background belief that women have a strong sense of duty; that their work is only a stop-gap until the children come along; and that the man’s wage is effectively the main source of income for the household. Titmuss, at the end of his Millicent Fawcett Lecture of 1952 on ‘The Position of Women’, acknowledged that four million families in Britain were enjoying a higher standard of living because women were going out to work.60 In 1958, lecturing at a conference on the first decade of the Welfare State, he managed to link women’s employment to full employment and both together to the downward trend in deprivation: ‘The fundamental reason for the relative absence of poverty, hardship and bad health among the workingclasses since 1948 is the fact of full employment and (we must certainly add) the great increase since 1948 in the paid employment of wives and mothers.’61 What passages such as these confirm is that Titmuss neither ignored the rising participation rate of women in the economy nor believed that the reproducers should remain in the kitchen so that the producers can get on with the job. Even so, there is a complacency in his view of women which is a reminder to the reader that God is a father, paternalism one stop before patriarchy and brotherhood – ‘fraternity’ – a universalism that excludes. Titmuss’s life at home with Kay (‘It was a perfect division of labour – exactly what families exist for’62) must have contributed to his vision of a biology-based order in which the woman’s career will normally be subordinated to her role as wife and mother. The economic base of post-Marxian socialism, as Ann Oakley perceptively points out, tends in itself to subordinate gender issues to the real issues: ‘Ideas about equality were primarily ideas about men defined in traditional occupational-class terms. The welfare state was about reducing class inequality. What it might or should do about women’s unequal chances compared to men’s was marginal to the main agenda, if, indeed, it was there at all.’63 Whatever the reasons for his tacit acceptance of ‘women welfare’ as a taken-forgranted sub-system in his theory, the fact remains that he was too complacent about the different social experiences of men and women,

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less than sensitive to the constructive use that could be made of welfare policy to resolve the specific problems that must have been uppermost in the minds of his students and his colleagues (the majority of them women) when they filtered his lectures through their own conflict of loyalties. Titmuss’s welfarism must evidently be extended if it is to provide an adequate response both to long-standing feelings of exclusion and exploitation and to the changes in economy and society that have had so great an impact on women’s life chances and expectations. As the two-career, two-income household becomes the norm, as divorce or desertion throws up a significant number of one-parent families, as part-time opportunities (often at low rates of pay) liberate women from the home but offer them neither job security nor occupational welfare, so there is a need for public policy to be able to satisfy new demands at the same time as it responds to the unhappiness of long-ignored aspirations. Thus social welfare could ensure the provision of nurseries and affordable childcare so that women can take jobs outside the home. It could protect women-only hospitals despite the lack of scale economies and guarantee hostels for battered wives when family life goes wrong. It could upgrade state pensions in line with earnings (de facto discrimination in favour of women because of their longer life-span) and ensure that child benefits are generous (many single parents live on or near the poverty line). Social welfare, more imaginatively, could even pay a social wage to housewives and carers for the quasi-social service which they provide. There is much that social welfare can do to respond to changes in the traditional sex roles. Importantly, however, economic welfare will have a contribution to make as well. A buoyant labour market protects part-timers, late entrants and the semi-skilled from the safety-valve function which has so often been women’s unique contribution to labour-market flexibility: ‘Mothers and wives’, Titmuss writes, ‘are likely to be affected first by any rise in unemployment.’64 Regulatory intervention reduces discrimination in hiring and promotions policy, guarantees paid maternity leave with the right to return, permits reasonable absenteeism where a family member such as a child is ill. Since the Welfare State (although disproportionately an employer of female labour) has itself left women underrepresented in senior positions, it is to be inferred that public service as well as private commerce could well stand to reap a welfare gain from control.

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(b) The origins of welfare Titmuss always emphasised that welfare is by definition in flux. Speaking in Denmark on policy, it was the crux of his message that no agenda can ever be permanent, unalterable, sacrosanct, oncefor-all: ‘Asked to talk about “The Welfare State”. Personal dislike of the term . . . Implies a static approach to society. A state of completion. A kind of welfare conservatism and welfare Marxism. Insufficiently dynamic. Contradicts “society in process”.’65 Things change, perceptions change, and open-mindedness is all. Continuously, pragmatically, ‘we need to revise existing concepts of what constitutes a social service’.66 New challenges (atomic energy, insecticides, ‘the effects on water-supplies and sanitation of the scientific development of detergents’) must perpetually give rise to new services: ‘In a multitude of devious and indirect ways, the social services are assuming a host of new responsibilities and costs as a result of advances in knowledge which benefit the whole of society.’67 Extinct volcanoes, although Titmuss does not say so, must presumably be made subject to an analogous process of review in order that resources might be transferred into areas of sunrise deficiency. The precise, named services will – and must – come and go. There is, however, one thing which is not open to renegotiation. That irreducible constant is necessarily the selective standard by means of which the social sector is properly to be singled out: Whatever our ‘angle of vision’ may be we shall eventually have to take account of two elements in any definition of ‘social policy’, the ‘welfare state’, and so on. The first is the extent to which any society identifies and recognises ‘needs’ – needs for food, housing, education, income maintenance, medical care and so forth. The second is the extent to which these socially recognised needs are met in the interests of the individual and/or of society through the provision of collectively organised services – in cash or in kind.68 The first element relates to fundamental needs that must not be conflated with self-perceived wants. Neoclassical economics makes the calculus of choice an emanation from subjective individualism, from tastes and preferences. Social policy, on the other hand, must take a more detached, a more objective view on the prerequisites

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for socio-biological survival. Wants in the real world – consider the final demand for food or shelter, the intermediate demand for skillformation to earn access to the spendable income – will often produce the same choices as will needs. In the words of Doyal and Gough: ‘You can need what you want, and want or not want what you need. What you cannot consistently do is not need what is required in order to avoid serious harm – whatever you may want.’69 The choices will often converge. The causal explanations, however, will never do so. A want is a surface perception. A need is an underlying condition. They are not interchangeable and not the same. The first element in Titmuss’s selective standard relates to the specification of the need that is not – just – a want. The second element brings in the State. In referring to ‘the provision of collectively organised services’, Titmuss is associating social policy with a politicisation of cash and kind such as distinguishes his subject from informal transfers between family members or the private charity with an agenda of its own. The second characteristic of a social service in the sense of Titmuss is quite explicitly ‘public provision to meet specific needs’.70 If the ‘specific needs’ in question were already being met through demand and supply, there would be no need for ‘public provision’ to correct a market failure. In that sense, and as a matter of simple logic, ‘a redistributive element is present; it is the result of a public recognition of a specific need, and takes the form of a transfer from the whole (or part) of the population to a particular group composed of heterogeneous income categories but having in common a specific characteristic of need’.71 Social policy is always and everywhere about the redistribution of opportunities and endstates – from the old to the young, from the healthy to the sick, from the productive to the unemployed, from the urban to the rural, from the past to the present, from the present to the future. Seen in that light, the well-publicised redistribution from the rich to the poor turns out to be only one form of social engineering among many: ‘All forms of public intervention in the life of the community do not, in their total effect, suggest a one-track one-way stream of traffic for ever converging on a proletarian terminus. On the contrary, I am reminded of Crewe junction; of flows of traffic coming from and going to all stations.’72 The welfarist State exists to meet specific needs wherever they arise on the social map. Social policy is not – just – the corrective of the top-down divide: ‘To prefer the simplicity of the single-line proletarian track to the complex dynamics of Crewe is to fall into the outstretched

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arms of uncomplicated Marxian dialectic.’73 The truth is the whole. It cannot be the part.

Titmuss defined social policy in terms of uncorrected need and of political intervention – and, most of all, in terms of the collective consensus upon which both elements were fundamentally dependent for their ethical legitimation. Titmuss carefully chooses phrases like ‘society identifies and recognises’ and ‘socially recognised needs’ in order to leave no doubt as to the nature of the imperative: ‘It is the public recognition and agreement to provide for a common characteristic of need that is important; not redistribution as an aim or effect.’74 Primary is the perception – ‘of society’s will to survive as an organic whole’, ‘of the expressed wish of all the people to assist the survival of some people’75 – and not the meaningless tautology that limited resources can always be reallocated and then reallocated once more: ‘It does not appear . . . that the criteria of redistribution . . . is of any value in defining a social service.’ 76 The precise beneficiaries (‘some people’) will only be known once the social consensus (‘all the people’) has arrived at its choice. The social consensus, in other words, is the sole agency with a map and an itinerary at Crewe. The simple opportunity to intervene and to assist can never be more than a necessary condition. Without the goahead from the group it must always remain insufficient. Titmuss saw the social consensus not as a sociological abstraction but as a social fact. Consider health policy in Tanganyika – where everyone wanted medical care to be improved. Consider population policy in Mauritius – where no one wanted living standards to fall. Consider the National Health Service in Britain – where unanimity of consent made it inevitable that citizenship pooling and free-on-demand delivery should become the norm. Cases such as these illustrate the general principle, that because we agree, therefore welfare is. Agreement, not the Bible, the Social Welfare Function or the General Will is the ultimate source of ought-ness in respect of the definition of a social service. James Buchanan, writing from the free-market ideological camp, was able to defend his own constitutionalism through an appeal to the same democratic contract: ‘Values are widely acknowledged to be derived from individuals, and there are not absolutes. God has been dead for a century, and attempts to revive him are likely to founder.’77 Titmuss expected agreement among

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fellow-citizens with common values. Buchanan, predicting diversity and welcoming pluralism, was less confident that conformity and compromise would steer a modern nation in the direction of the Golden Mean. In the one case as in the other, however, agreement is freedom – and disagreement creates a vacuum. Titmuss, unlike Buchanan, can hardly be called a misanthropic Hobbesian. The bias in Titmuss’s case is more likely to be in the opposite direction. Introducing dissensus, acknowledging disagreement, the modifications that would have to be made to the real-world role of social policy could leave it far less effective as a watchdog than is envisaged in Titmuss’s positive proposals. Thus the nature of a need with an objective existence might not appear the same to all members of the community. Titmuss, although he does not spell out in detail what it means to be a part of homo sapiens, would probably have favoured a broad definition such as that provided by Abraham Maslow when, not limiting himself to the gratification of the bodily needs like shelter and nutrition, that much-read humanitarian proceeds sequentially to the satisfaction of higher, socio-psychological needs such as safety and security, integration and rootedness, esteem and purposiveness, self-realisation and self-actualisation.78 Others, unimpressed by so universal and so categorical a vision, will favour the narrower definition of the physiological standard while leaving it to each individual to choose his own becoming (in the sense of Green) or his own fixation (in the sense of Freud) in his own unique way. Given the potential dissensus as to the nature of ego’s need, given the potential dissensus as to the extent to which ego’s need is a collective concern, the possibility must be recognised that a need with an objective existence as defined by Titmuss might have to be left unmet because subjective rankings legitimate only residual support for the homeless sleeping rough, for unemployed alcoholics with a history of petty theft, for traumatised refugees who need a skill, for unmarried mothers with nowhere to go. Titmuss did not anticipate that fundamental needs might not be labelled as fundamental needs by a median citizen with little tolerance of weakness or failure – and, still less, that the social consensus might not care about others at all. The legitimate non-fulfilment of basic human needs is one problem which arises once value-dissensus is admitted into the Titmuss model. Ambiguity and dissatisfaction within the agreed-upon welfare package is another. Titmuss, attacking vertical differentiation,

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expressed his support for ‘one publicly approved standard of service, irrespective of income, class or race’.79 Titmuss, defending horizontal differentiation, came down strongly in favour of ‘a respect for the unique value of each individual and his or her need for self-respect, independence and dignity as a citizen in work and old age, in childhood and adolescence, in sickness and disability’: ‘Cultural diversity in the instruments of welfare is a precious asset in a world of more and more standardised products.’80 On the one hand the same restaurant, on the other hand a choice of dishes – Titmuss clearly believed that the heterogeneous could be accommodated within the homogeneous in an umbrella consensus where the common culture does not presuppose that everyone should wear a uniform and that even Muslims should eat pork. On the one hand the consensus accepts the need ‘to provide a strong enough basis for the common life to enable people to cope with their inequalities in such a way that they do not fall into envy, malice and the denial of charity’.81 On the other hand the consensus is the party of freedom and the champion of taste: ‘The spread of conformity means injustice.’82 Titmuss may have underestimated the extent to which the differentiation of preferences can prove a threat to common-culture welfare in a mobile and a competitive society. Thus parent A will want comprehensive education (to minimise stigma) while parent B will want streaming (to maximise accomplishment): even the suppression of non-state schooling will not resolve the win–lose dissensus that divides A from B. C believes that local authority tenants should be charged economic rents, D that there should be means-tested rents differentiated by the ability to pay, E that the citizenship option is flat-rate subsidised rents that treat like as equal: building more estates will not resolve intrawelfare disagreements such as these. There is no single public opinion on the provision of social security to the deprived families of men on strike (whose action may cause thousands of others to lose their livelihood and be forced themselves on to benefits); nor as to whether the irresponsibly large families of careless people (often of another confession and therefore doubly suspect) should be bailed out of self-imposed misery; nor as to whether a woman cohabiting with a man not her husband should be denied a widow’s pension. Dissensus in instances such as these cannot be resolved simply by pointing to consensus on the need for the State. Welfare in place, that can be when the bitterest of the value-conflicts begin. The point is that value-differences often reflect fundamental

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cleavages in society, and that, where they do, social policy might be quite unable to reach a compromise on the basis of a unique social will. There may, for example, be value-conflict between those citizens who demand free contraception for the under-aged and abortion as of right on the National Health, and those who disapprove of scarce social resources being utilised in this way: here, to choose one policy based on one morality is to alienate the sympathies of those who want an alternative policy based on an alternative morality. Again, to take a second example, there may be value-conflict as a consequence of value-divergence in the case of governmentally mixed communities: where one view is that the privileged should be allowed to exclude the non-privileged by price and another view is that the neighbourhood should be made a cross-section of the nation, bargaining will be out of the question and one set of aspirations will have at the end of the day to be scrapped. Titmuss says little about the resentment of pensioners sentenced to death because their demand for a transplant is called a want and not a need by the Service. Nor does he acknowledge the sadness of savers prevented by death duties from passing on to their children the full fruits of a lifetime of labour. Where there is a conflict of values, universalism will always be at risk from the threat within. The imposition on one group of another group’s values is as likely to deepen social division as it is to foster social integration. Titmuss shows little interest in value-conflict and the divisiveness it can produce. The reason is almost certainly his propensity to treat welfare at a high level of generality (health policy: everyone wants to be well) and not at a low level of specificity (organ bigotry: the donor will give only if the beneficiary is white). One consequence is that there is little in his work about the tyranny of the majority: it was to ‘the poor and the coloured population’ (and not to middle-class parents denied fast-track education because gifted high-flyers discourage the mean) that Titmuss was referring when he wrote that ‘one crucial test of the degree of accepted social responsibility in a community lies in its treatment of minorities’.83 Another consequence is that there is no real account in his writings of the techniques that decision-makers should employ to capture the sense of the social will – and the degree of dispersion that separates the tails from the median that has salience but not necessarily philosophy on its side. Social consensus and social dissensus are by their very nature imprecise. Titmuss, assuming convergence and expecting agreement,

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was content to rely on impressions since common perceptions are not difficult to access. He does not say how states of dependency or welfare projects could be ranked at the margin in terms of quantifiable indices derived from subjective sensations. He cites few case histories of particular programmes where governments successfully determined the content of the collective consciousness as the first step towards reaching the targets that it prescribed. While his theoretical bent is a welcome antidote to the trivialities of the short-story approach to social policy, the fact that he does not explain how public opinion can be turned to good use in setting priorities and adjudicating disputes between services means that the exact nature of the link between social intelligence and social welfare must remain a focus for conjecture. Titmuss, not strong on the reconstruction of the representative, finds no room in his world-view for two discovery mechanisms which might, conceptually, give an insight into the consumer-citizen’s concealed valuations. One of these is the market: success indicators like profit and utility indicators like price have no place in an intellectual system which is resistant to the use of money as a index of achievement. The other is direct consumer consultation. Gunnar Myrdal gives a sense of citizen involvement as one of the main reasons in Sweden for citizen satisfaction with the Welfare State. His argument is that the dependent, like other people, want not just income-sharing but power-sharing as well: When participation is on a low level, we should expect people to be more apt to feel that the regulations are imposed upon them from above and that they are being pushed around by ‘them’ – the bosses, the bureaucrats and the oligarchies in the organisations, the strange and distant forces in Wall Street and Washington. This might breed feelings of resentment, and will anyhow frustrate people’s feelings of solidarity and identification with the purposes of the regulations.84 Middle-class owner-occupiers shop around for the fitted kitchen and the loft conversion that help them to make their dreams into a lifestyle. The deprived family must accept the high-rise flat at some distance from the children’s playground and the parents’ place of work that the welfare professionals deign to put at their disposal. Consultation in such circumstances would moderate the unequal distribution of the power cake that would otherwise make

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welfare itself a locus of social distance. Crucially, it would also make clients’ tastes and consumers’ preferences known to the administrators and the planners before they made expert opinion the sole determinant of the welfare package. Titmuss was sensitive to cultural stratification and sub-cultural segmentation. Non-judgementalism to him meant that equal humanity was deserving of equal respect. Speaking of the lower classes (more likely than social workers to smoke, less likely than case officers to save), he advised that gift cherubs should not too frequently be asked to bake biscuits for a Women’s Institute fête: ‘There is the danger of assuming that the norms of one class are relevant to the needs of another.’85 Speaking of black immigrants (abnormally exposed to a conflict of perceptions, abnormally prone to feelings of exclusion), he insisted that it is forever cricket to back different teams within the broad church of a single sport: ‘By integration I do not mean assimilation; the purpose is not to turn these neighbours of ours into “good little Englishers”. By integration I mean equality of opportunity and the fostering of multiple loyalties.’86 Sensitive to variation, in favour of acceptance, it would in the circumstances have made sense for Titmuss to have included community involvement and democratic consultation in a system which is expressly legitimated bottom–up. Autocracy and passivity being the undesirable by-products of ‘outer rather than inner observation’,87 there is clearly a case for Titmuss’s system to be extended in such a way as to incorporate grassroots sensibilities alongside the objective needs that are the province of the professionals. In practice, grassroots sensibilities in the welfare sector are often made the private capital of pressure groups. Titmuss could usefully have said more about the associations, charities and unions which lobby on behalf of claimants, children, addicts, students, social workers, probation officers and other actors in the welfare drama. Pressure groups represent the interests of the pools for which they speak. Whether they do so with any real authority is less obvious. The representation is typically indirect (with the implicit threat that the organisations will not fully mirror the sentiments of their members), often undemocratic (as where the groups are the self-appointed spokesmen for constituents who do not know of their existence, or where an unelected leadership is unaccountable to the rank-andfile), usually arbitrary (as in an attempt by town-planners to redeem an urban disaster area, where problems are multiple, criteria complex, and it is not clear whom to consult), and always unequal (since

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not all pressure groups enjoy pressure parity, making a dispute between the representatives of the long-term mentally ill and the representatives of the consultant psychiatrists into an all-but-certain victory for supplier sovereignty). The relationship between pressure groups and client values is self-evidently a problematic one. Filling in the gaps in Titmuss’s model, it would be a useful contribution to show how power and militancy act to defend interests and convictions which in an ideal world may be refracted through the groups but will none the less take their origin in perceptions from below.

Titmuss, like Tawney, proceeds consensually, bottom–up. The Webbs, like Keynes, proceed expeditiously, top–down. The former standard relies upon Henry Dubb to reveal what he prefers. The latter standard relies upon the skilled dentist to select a suitable drill. Both standards are present in the hyphenated welfarism of the prudent T.H. Marshall. T.H. Marshall, like Tawney, derived his model of ‘mutual aid on the basis of common citizenship’88 from overall agreement in the society as a whole: ‘Without a foundation of near-consensus, no general social welfare policy would be possible.’89 Without such a foundation, ‘there could be no welfare state’.90 Marshall, philosophically a welfarist himself, was therefore pleased to report that, in modern Britain at least, ‘a very high degree of consensus exists about the aims of the welfare services’.91 Yet T.H. Marshall, like the Webbs, was also prepared to countenance democratic leaderliness where popular choices left the fabric exposed. Thus the government should not hesitate to frustrate expectations where the requests articulated were of a low order of importance: ‘Although it must take careful note of expressed desires, it does not simply react to or obey them. Its responsibility is to satisfy needs, which is a different undertaking.’92 Besides that, the government must make itself the guardian of productive efficiency and economies of scale even as it seeks to guarantee to the consumers of welfare the right to demand-led supply: ‘You cannot make the optimum use of scarce skills and resources in a nationwide service open to all if you allow every applicant for its help to pick and choose as he pleases.’93 T.H. Marshall was normally prepared, like Tawney, to make Henry Dubb the architect of welfare. Sometimes, however, he believed that he had to look to the politicians and the bureaucrats to take a lead.

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In his theory of welfare Titmuss was closer to Marshall on consensus than he was to Marshall on supply-side initiative. It is interesting, and indicative, that he cites few if any constructive contributions that were made to social policy by ‘Great Men’ like Barbara Castle (in respect of pensions), or philosopher-rulers like Anthony Crosland (in respect of schools). Even the personal impact of Aneurin Bevan on the Health Service, hardly acknowledged at all, is treated implicitly as if the input of a public servant and not that of a visionary engineer. Both in terms of explaining what has gone before and of recommending how public policies ought to come to the surface in the future, it is possible that Titmuss was actually too modest and not too ambitious in the role that he assigned to the lead. There is, of course, another view that can be taken of Titmuss on the State – that by being so complacent about the sensitivity of politicians, the seemliness of bureaucrats, he unintentionally concealed the perversion of democracy and the suppression of voice that can be the creeping consequences of ‘the road to serfdom’ in conspiracy with ‘the new despotism’. Tawney writes that the State in a mature democracy can safely be treated as a ‘serviceable drudge’ and not a ‘bloodthirsty Leviathan’: ‘We, in England, have repeatedly re-made the State, and are re-making it now, and shall re-make it again. Why, in heaven’s name, should we be afraid of it?’94 The critics of peaceable statists like Tawney and Titmuss have never been reluctant to provide an answer to the question. Consider first politicians. Anthony Downs has developed an economic theory of the political market according to which elected officers, self-interested and calculatively rational, sell policies (their ‘products’) in order to maximise votes (their ‘profits’). Such cynical opportunism, unfamiliar though the vision of principle-less commercialism will normally be in developed democracies that frown on bribes, at least implies that the merchants will have to please the voters in order to retain their seats. The popularity-chasing, sadly, can have a displeasing under-side as well. Because of the need to score a five-yearly victory in a general election contested on a bundle of issues, the leaders might target public spending on high-profile projects and marginal constituencies while underfunding the controversial, the unglamorous and the boringly obscure. By the same short-horizoned logic, and recognising with O’Connor that ‘every economic and social class and group wants government to spend more and more money on more and more things . . . but no one wants to pay new taxes’,95 they might

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offer too many free gifts relative to what the voters are prepared to support in the knowledge that deficit-finance can make future cohorts the sponsors of the present day’s consumables. Also, as Downs makes clear, the economic reality that voters normally earn in one market but always spend in many makes legislation disproportionately favourable to the producer precisely because the consumer does not find it cost-effective to become informed: ‘Rational ignorance among the citizenry leads governments to omit certain specific types of expenditures from their budgets which would be there if citizens were not ignorant.’96 Marx and Engels, taking the view that ‘the executive of the modern state is but a committee for managing the common affairs of the whole bourgeoisie’,97 predicted government failure as a direct consequence of the market economy. So, interestingly, does Anthony Downs – who for that reason sees a case for the mixed economy to become more skewed towards exchange. Politicians can be popularity-chasers. They can also be manipulative Machiavellians with ideological objectives of their own. Not the passive servants of widely held social values but conviction zealots who are certain they know best, the possibility is real that they will proclaim social policy from above without awaiting instructions from the vagueness of a consensus in which they have no strong faith. As Buchanan puts it: ‘Within what he treats as his feasible set, the politician will choose that alternative or option which maximizes his own, not his constituents’, utility.’98 The brainwashing and the refamiliarisation come first in the causal sequence. The new consensus and the self-validating acceptance need not for all that lag far behind. Thus a sense of community might be the result and not the cause of mixed neighbourhoods; while population movements into the new housing estates might in any case alter the electoral bias of the locality in such a way as to ensure the vote-winning potential of geographical comprehensivisation in the future. Critics of centralised power have traditionally complained that there is a genuine threat to individual liberty in political initiatives such as these. Devolution is one answer – since local government is that much closer to public opinion on the spot. Privatisation is another – since ‘economic strength’, as Milton Friedman explains it, would then be in a position ‘to be a check to political power rather than a reinforcement’.99 Titmuss believed that political power can be a vital corrective to economic power, a locus of countervailing power in a society that had known abuse and neglect. What he was unprepared to accept

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is that political power can be a cause of new grievances in itself. The possibility of coercion is of especial concern in the field of welfare, since there the public sector arrogates to itself not simply the right to regulate but the power to provide. Titmuss, writing of the government’s wartime efforts to convince parents of the need to evacuate schoolchildren from the cities, records the following fact: ‘The art of democratic persuasion, of making people feel confidence in the Government’s plans, had to be practised.’100 Here he seems content that plan should antedate persuasion, just as it does in the mature corporation of Galbraith’s New Industrial State. Presumably this is because he is arguing to himself that no parents, understanding the issues, would really want their children to be exposed to the Blitz. If, however, ‘the art of democratic persuasion’ is truly a powerful weapon, then it is not clear why politicians should ever turn first to the elusive collective consciousness when it is in their power to make a change and only afterwards to mould consensual attitudes into the image desired. The temptation for the sensible to take a lead must have been a strong one for a man of principle like Richard Titmuss. Giving a talk at Balliol College three years after the publication of Downs’s Economic Theory of Democracy, he left his listeners in no doubt that politics for him was not just another name for buying and selling: To me, the business of socialists is to change society in accordance with socialist ethics. It is not, first and foremost, to achieve power. To put power first must mean ‘studying the market’ today; an impressionistic market research view of what the new working-classes are demanding. This may well be – in the next 20 years – reactionary – e.g. materialism; capital punishment; homosexuality; inequality etc. We have not educated them. It is easy to criticise the T.U.s for manual workers; but we have to try and understand the reasons for their narrow view.101 Their view is ‘narrow’. Socialists have not ‘educated them’. Leaders must not put ‘power first’ where the price is their ‘socialist ethics’. Unpublished notes for a talk at Balliol College cannot be taken as proof positive that Titmuss was at heart a moulder and not a follower of consensus. What they do show is that a man of principle who is also an unwavering democrat will inevitably face the same conflict of interest as does the doctor when employed by his customer to supply cocaine.

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Tawney, unafraid of the State, denied that politicians were necessarily doomed to sink into the role of despots: ‘It is as possible to plan for freedom as for tyranny.’102 Titmuss, sharing his confidence, also saw that Tawney’s rejection of minimax was a direct reflection of Tawney’s own way of life, ‘a realisation in action of his own high principles’: ‘The severest criticism of Equality as a social theory is that it would be easier to realise in practice if all men were Tawneys.’103 Titmuss was a pragmatist and a man of caution. Referring to politicians, however, he tended none the less to write as if ‘all men were Tawneys’ – and they were not. As with politicians, so with bureaucrats. Max Weber treated the civil servant as compliant, faceless, powerless, obedient: ‘In the great majority of cases, he is only a single cog in an ever-moving mechanism, which prescribes to him an essentially fixed route of march. The official is entrusted with specialized tasks and normally the mechanism cannot be put into motion or arrested by him.’104 Titmuss shared the vision of the civil servant as an instruction-follower and a function in a structure. Passive and reactive, accountable to his nation because he is responsive to his superiors, the civil servant is always our servant and never a self-interested entrepreneur with goals and purposes of his own. Anthony Downs sees the survival of sharp elbows as a reason why good Weberians tend to be pushed aside by social deviants with little interest in the social consensus: ‘Men who enter bureaus and consistently evidence statesmanlike behavior are rarely promoted . . . It is our ironic conclusion that bureaucracies have few places for officials who are loyal to society as a whole.’105 Titmuss, on the other hand, never doubts, with Weber, that office-holders on balance take professional pride in doing what their principals demand. Titmuss recognised that salaried managers of private corporations could have behavioural goals of their own, purposes quite different from those of the profit-seekers who were in law their masters. He was, however, more reluctant to accept that administrators in government departments and parastatal bodies could themselves be blinkered by interest or exposed to temptation. The fact that civil servants seldom take bribes and show no overriding obsession with money seems to have convinced him that the ministries cannot realistically be regarded as a major locus of non-consensual or counterconsensual conduct. He would have been more concerned had he been more open to the personal and private objectives, not directly pecuniary though these may be, which can divert the officeholder from his Weberian duty.

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Prominent among these organisational goals will presumably be job satisfaction (which may induce a service to undertake highly specialised research for which there is no objective need and of which the consensus would never approve were it in a position to penetrate the jargon of boffinism), security (which may prevent a service from winding itself up when it has served its purpose or decisively failed to do so), autonomy (which may cause a service to flee from the audit and the publicity of the interdepartmental committee into the protected secrecy of the parallel hierarchy) and growth (which may stimulate a service to expand, irrespective of the rationalisation it provides to itself and others, principally in order to generate more opportunities for promotion and more fiefdoms of power in a world of intra-mural empire-building). In order to retain the freedom to pursue microsociological objectives such as these, a service will want to impress with its successes and to avoid embarrassing failures that could cause questions to be asked. Its incentive structure is such that it will be led by its own self-interest to divert marginal resources from slow learners and confirmed recidivists in order to concentrate help on the ‘good-risk’ dependent most likely to make spectacular progress at minimum cost. Such a policy of playing safe is, needless to say, the opposite of what Titmuss intended when he called for selective discrimination. The problem of organisational goals is compounded by that of organisational aggregation. Given self-interest, what can emerge is an aimless proliferation of schemes essentially because each group wants to be at the centre of one project or another. The resultant tangle (combined with the inflexible demarcations of professionalism itself) need not represent either an efficacious response to need or a comprehensive and coordinated structure of services. In the real world, what passes for planning is often no more than the weary compromise ground out by the deal-making and the negotiating of supply-side coalitions. Power-rating may sway the balance (although strength is not the same as wisdom); and so might the practice of settling disputes through an appeal to precedent. Caution and myopia can be a significant cause of waste and delay. They can also mean that there might be inadequate opportunities for a self-correcting response to originate within the social service matrix itself. The perpetuation of established patterns can be at variance with the attainment of wider social goals. Titmuss, stressing the evolving nature of the Welfare State, observed that the inability to recognise

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the ‘all-pervasive character of social change’ had in the past ‘prevented us from understanding that all legislation is experimental and that a social service is a dynamic process – not a finished article’.106 He called for flexibility and sensitivity in order to ensure that the social services change in accordance with changing social needs: The forces of the past in terms of how we live together in society create new situations; if the structure and functions of the social services cling too closely to the needs of the age when they originated, and if the interests which resist change become too powerful, these services will not meet the needs of the new situations. We shall not achieve a better balance between the needs of today and the resources of today by living-out the destinies of tradition.107 Titmuss recognised that inertia resulting from the vested interests and the professional conventions of the Welfare Establishment itself could be a cause of retarded adaptation and the perpetuation of the status quo. What he denied was that the nightmare scenario must necessarily be the normal one. His followers will no doubt add that organisational redesign (in the State as in the corporate sector) can contribute much to the improvement of performance – and that even competition between state schools, between state hospitals, will prove more attractive to the social consensus than would the privatisation that the critics of bureaucracy so often cite as the solution. Titmuss could usefully have said more about the organisational obstacles to consensus-led welfare. Writing as a sociologist, he obviously did not regard the obstacles as especially serious ones. Writing as a reformer, interestingly, he seems to have found the prevalence of Weberian self-abnegation the greater cause of concern: Bureaucrats and ‘professionalized’ people, whether employed by large-scale private or public organisations, have one attribute in common: a self-image of political neutrality. This rests on the belief that administration can be wholly rational . . . These and other forces encourage rather than discourage a climate of opinion which is detached about injustice, inequality and the position of minorities. There is a truce about values. There is a demand to take health and social welfare ‘out of politics’.108

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A philosopher, a socialist, a policy-maker, Titmuss pointed with unease to developments in society which were ‘tending to enlarge the area of power of forces which are openly or tacitly hostile to research topics which carry – or seem to carry – overt political implications’ – developments such as the Weberian blandness of the organisational revolution: ‘The growth of bureaucracy, in public or private structures, as a consequence of large-scale organisation, is one such force.’109 The nation needs wide-ranging new research, not least into neglected areas where the facts can present a challenge to complacency. Civil servants, however, precisely because they are self-effacing Weberians, try to filter out the controversial lest it prove an embarrassment to their political heads. Research into widows’ benefits, Titmuss reports, was just such a case of a potential upset identified and defused: ‘Any shrewd administrator worth his salt to the Treasury, was bound to be struck with the thought that the findings of research on this aspect of the inquiry were unlikely to recommend a reduction in benefits.’110 Harmonious functional integration in the non-market sector presupposes continual review and revision of policies in combination with impassioned struggle for justice and inclusion. Civil servants, however, precisely because they are the self-effacing servants of an easily embarrassed Cabinet, tend to have an independent impact on the welfare that is supplied. Social policy in the sociology of Richard Titmuss must bubble up from the social consensus. Social policy that originates on the side of supply must in the circumstances always stand out as a cause of concern.

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Part Two: Selectivity

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5 Stigma

Titmuss believed that the State should provide a range of free welfare services. He also knew that resources are limited and that there is a need to ration supply.1 Clearly, and even if resources are not to be rationed by price for all comers, there is at least a case for a dual system whereby those who can afford to pay for welfare rely on private provision, and the State (rather than providing welfare benefits indiscriminately) concentrates its help where the need is greatest and the ability to pay least. Titmuss, however, rejected such selectivity. Partly this was because of his belief (the subject of Part Four) that private enterprise in the field of welfare is a mixed blessing even for those who can pay. Partly it was because he was convinced that a dual system involves stigma. Stigma means a loss of self-respect and personal dignity, a sense of guilt, of shame, of personal fault or failure. It means the sensation of second-class citizenship that results from discrimination. It means what Goffman calls ‘spoiled identity’,2 since discrimination so easily becomes self-discrimination. To begin with this operates at the level of perception: ‘If men and women come to think of (and feel) themselves as inferior persons, subordinated persons, then in part they stigmatise themselves, and in part they are reflecting what other people think or say about them.’3 Later, however, the process of self-stigmatisation seeps through to the level of action: ‘If men are treated as a burden to others – if this is the role expected of them – then, in time, they will behave as a burden.’4 Whether at the level of perception or at the level of action, such psychological damage is undesirable. It arises in a selective system in three ways.

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First, there is the stage of trying to obtain private insurance or private treatment and failing because one is an actuarial bad risk. It would be uneconomic for the private market not to exclude those who cannot pay or are likely to make excessive demands on resources. It would also be unfair to the shareholders were private enterprise to redistribute the national income by, say, undertaking to charge non-weighted insurance premiums to patients with aboveaverage medical needs. At the same time, however, this leaves the disadvantaged in a state of neglect. It may be that people ought to stand on their own feet and spend according to the dictates of their own conscience and purse. Yet they cannot be expected to buy services which the vendor is unprepared to sell. The fact is that the private market does not provide adequate welfare services for such groups, potentially at risk, as the deprived child, the single parent, the woman over 40 entering the labour force, the widow, the educationally deprived, the unemployed, the mentally handicapped, the mentally ill, the physically handicapped (such as the deaf or the blind), the bedridden. It often neglects the non-white immigrant, the striker, the unsupported wife, the worker on a work permit, the intermittently employed agricultural worker, the ‘elderly isolates and desolates’5 of society. It does not provide treatment for the drug addict, the indigent, the impoverished schizophrenic newly discharged from hospital. In America the whole of the urban ghetto is often declared an uninsurable risk. It must be remembered too that, in an increasingly mobile society, a number of those rejected by the private market will not have families on which to fall back.6 It is possible that many of these potential losers apply for private insurance or treatment and are rejected without right of appeal. Not only is this a denial of freedom of choice to large groups of would-be consumers, but lack of access to essential facilities leaves the felt and experienced need among such vulnerable groups without proper remedy. It also leaves the dependent with the bitter taste of rejection, exclusion, powerlessness and indignity. In some way, whether on grounds of race, poverty, mental fitness or some other judgemental yardstick, society is seen to have expressed its disapproval and selected them out. Such stigmatisation is the order of the day for many groups in modern society. It is, however, largely invisible: the insurance companies collect no statistics on ‘the psychological and social harm they do to people’7 in rejecting them or rating them as sub-standard. It is hard to see in any case how a sense of stigma could be precisely quantified.

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It has been argued that affluence and full employment will cause this first kind of stigma to disappear over time. The aim of state provision of social services, so the argument goes, should be selfliquidation as more and more people become eligible for privately provided welfare: ‘Such pockets of poverty and residual distress as still prevail will in time automatically and gracefully succumb to the determinism of growth. This will be achieved by a natural process of market levitation; all classes and groups will stand expectantly on the political right as the escalator of growth moves them up.’8 The fallacy here is the assumption that the increase in command over resources will be evenly and proportionately distributed between spending units. Titmuss quotes American evidence for 1966 (one child in four and three elderly persons in ten living below the poverty line, a move towards greater inequalities in income and wealth) to support his contention that economic progress need not naturally lead to social progress without redistributive intervention by the State. The ‘invisible resource allocation of the market’9 in a dynamic economy will not solve the problem of poverty and thus of stigma associated with the rejection of application for private provision. Embourgeoisement is not the answer, the way out.

Second, there is the stigma associated with the means test that is administered to applicants for state welfare in order to guard the gate of state-provided cash transfers and free services against those who can afford to pay for private support. The aim being to reach the desperate directly, they must first be separated out from a population which includes sheep as well as goats, non-poor as well as poor. The means test is a deterrent to abuse. It aims to help the poor by sparing them the need to share scarce welfare resources with all and sundry. Unfortunately, however, welfare provided on a discriminatory, means-tested basis has a tendency to ‘foster both the sense of personal failure and the stigma of a public burden’. Clearly, ‘the fundamental objective of all such tests of eligibility is to keep people out; not to let them in. They must, therefore, be treated as applicants or supplicants; not beneficiaries or consumers.’10 Yet ‘it is a regrettable but human fact that money (and the lack of it) is linked to personal and family self-respect’.11 No poor person wants to stand up and define or identify himself as poor, for to do so would be ‘to declare, in effect “I am an unequal person”’.12 Such a punitive

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process of selection, because it means a ‘humiliating loss of status, dignity or self-respect’,13 is too great an insult to be tolerable in a society that wants to protect the sense of self-worth. Quite apart from the indignities involved, means-testing is undesirable because of the administrative problem. Any test that acknowledges the fundamental truth that ‘there are no standard families with standard or uniform requirements’14 becomes an administrative nightmare due to the multiplicity of variables that must be taken into account. These variables, moreover, do not remain constant. Circumstances are in a continual state of flux caused by births, adoption, children leaving school, marriage and remarriage, desertion, separation, divorce, illness, disablement, retirement, death, fires and disasters, unemployment, a new job (possibly with a pay increase only just keeping pace with inflation), a new house (with a different rent), boarders, inheritance, institutional care for aged parents, capital appreciation, windfalls, and numerous other factors influencing the resources and responsibilities of spending units. Even if meaningful means-testing of families could be carried out, the results are likely very quickly to become out of date. Means-testing also makes it difficult to deal with urgent needs. In the case of, say, an evicted family with an unemployed father where an individual experiences a spell of sickness, the emergency must be dealt with immediately, and without the delay imposed by administrative intricacies. In any case, these formalities are bound heavily to penalise the most ignorant (who may well be the most needy). There are a multitude of different means tests (at least 1500 are administered by local authorities in England and Wales in welfarerelated areas alone). In the past the academics and the administrators have ‘overestimated the potentialities of the poor, without help, to understand and manipulate an increasingly complex ad hoc society’.15 The poor are not only stigmatised by welfare but may be excluded from it (not least where they have multiple needs necessitating multiple tests): ‘Who helps them, I wonder, to fill up all those forms?’16 A negative income tax operated through the Pay As You Earn network would help remove this administrative burden from the dependent by making benefits (albeit in the form of money, not services) automatically available, and based on a computerised code number. It would, however, face the same insuperable difficulties as any other test in attempting to estimate resources and shortfalls, to keep track of changes over time, or to respond quickly to

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urgent needs. It simply does not make sense to deal with this year’s emergency by applying a code number derived from last year’s data, based on a P.60 which may be seriously out of date.17 Naturally, employers could be asked to provide the Inland Revenue not with annual data but with weekly or monthly data, so as to keep the tax code up to date in a non-static world. The data could then be married on a continuous basis with other relevant data (as where, for example, husband and wife are assessed separately for income tax). All of this, however, is a waste of administrative resources (including the resources of private employers) and might not even be feasible (due to the multitude and complexity of ever-changing variables). As Titmuss says: ‘What I find frightening is the extraordinary administrative naivety of those who argue in such terms for “selectivity”.’18 Not only is any means test bound to be administratively unwieldy, but it is not able to deal mechanistically with the mass of difficult value-judgements that must be made at all stages in defining the criteria for eligibility. The basic decision is, of course, to specify in what financial circumstances an individual qualifies for income supplementation by the State. Yet this in turn raises other important questions and ultimately involves complicated social values. For example: should people who do not work be better off than people who do (the wage-stop)? Should a distinction be made between earned and unearned incomes? Should the test include a wealth test or ‘should income tests and charges disregard capital assets, house property, discretionary trusts, education covenants, insurance policies, reversionary interests, fringe benefits, tax-free lump sums, share options, occupational benefits in kind and suchlike?’19 Should wives be encouraged to go out to work? Should one distinguish qualitatively as to the cause of dependency (the same zero income, for example, might be earned by a striker, a layabout, a disabled war hero, or a student in the process of acquiring socially useful skills)? Naturally, once considerations of ethics and equity are brought in, ‘computers cannot answer these questions’.20 There is no escape from the human decision-maker.

Third, there is the stigma attached to separate provision, partly because the special facilities provided are clearly earmarked for failures and inadequates, partly because residual provision is invariably inferior provision. The truth is that ‘separate discriminatory services for poor people have always tended to be poor quality services’,21

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second-class services aimed at second-class consumers excluded from the middle-class world of welfare and conscious of that exclusion. The inferiority of public compared with privately provided services is to some extent a question of finance: ‘Insofar as they are able to recruit at all for education, medical care and other services, they tend to recruit the worst rather than the best teachers, doctors, nurses, administrators and other categories of staff upon whom the quality of service so much depends.’22 As far as the poor are concerned, however, ‘if the quality of personal service is low, there will be less freedom of choice and more felt discrimination’.23 Such felt discrimination is not an unintended outcome but a part of the system. Its roots may be found historically in a past society which attempted to reconcile compassion with individualism by treating the poor as the indigent, a public burden for whom a safety net had to be provided, but subject to the expression of disapproval. Rationing by shame and inferior quality of services provided is, however, no longer acceptable as a deterrent in the way that it was acceptable at the time of the New Poor Law of 1834. Then, ‘shame was needed to make the system work’.24 Nowadays, the collectivity is more likely to feel that the dependent should not be sanctioned with stigma, and that those who provide welfare should not see it as their duty to stigmatise the recipient for some supposed dereliction or failing on his part. To avoid the cumulative and demoralising effects of rejection on the individual, Titmuss therefore decided that social welfare services had to be provided free of charge, as of right, to all citizens, dependent on their needs alone and not on their means. In place of a selectivist system, where the State withers away until it performs merely a residual function, Titmuss believed that a universalist structure of services had to be made available to all, since liberation from state intervention was bound to increase the incidence of experienced disapprobation in society. The great majority of people using the National Health Service do not feel stigmatised, and the reason is that the Service is known and felt to be universalist in scope.25 The same infrastructure of facilities is used by the nonpoor and the poor alike (i.e. by those who could pay for private attention as well as those who could not). Selection is avoided and the dependent keep their self-respect. In Britain, just as a cat can look at a king, so an unskilled labourer can share a ward with a Professor of Social Administration. The avoidance of stigma is secured by opening social welfare services

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to all, regardless of class, colour or income. Naturally this great benefit substantially raises the cost of provision. But against that cost must be set the fact that universalism not only negates a previous negation but also constitutes a definite affirmation by making a constructive contribution to social growth in three important ways. These are the covering of social costs by social provision, the furtherance of a heightened sense of social integration, and the creation of a framework within which to plan the redistribution of life chances. These social benefits will be examined in Part Three.

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6 Part Two: Evaluations and Extensions

Dependent people are people with needs. People with needs should be treated with respect. The Good Samaritan applied no means test when he proffered relief to a stranger in distress. The Welfare State should take pride in the same non-judgemental compassion when it provides a guarantee not just of cash and kind but of self-worth and self-esteem as well. No one but a scoundrel kicks a beggar in the teeth. The welfare services in the sense of Richard Titmuss were a reaffirmation of community and identity, not just a soup-kitchen for failures and misfits: To me, the social services are not simply a means by which purchasing power may be redistributed, although that is – and will remain – a vitally important role for the social services. They are also concerned – and, in my view, should increasingly be concerned – with the quality of civilised living, with the condition of our physical environment, with our attitudes and values towards minority groups, the deprived and the poor, and with the diffusion of power and the multiplication of loyalties.1 The welfare services are not just alms-houses and Maundy money. They are also the non-calculative response of a national family that instinctively shares to the distress and unhappiness of all of its sons and daughters who stand in need of its love. That being the case, there can be no justification for looking the Prodigal Son shrewdly in the mouth or colour-coding the black sheep for blackness of fleece: ‘To be responsible for others means the acceptance of duties or obligations towards others without discrimination.’2 Dependent 98

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people are people with needs. They are not natural deviants who deserve to be hurt. Acceptance without stigma is absolutely central to Titmuss’s vision of the socialist alternative. Capitalism ranks – and the result is ‘pain and stress’: ‘The corollary for any society which invests many of its values and virtues in the promotion of the individual is individual failure and individual consciousness of failure.’3 Welfarism assists – since physical or psychological suffering can never be good: ‘Pain, nature-made or man-made, can be unmade or prevented by man; that is the lesson that is being taught. And it is being learnt if I interpret correctly the popularity of the National Health Service.’4 The witness to the mass rejection of Depression unemployment, the son of a father whose business had not made the grade, himself an outsider professor without deep roots in academic privilege, Titmuss had first-hand knowledge of second-rate status and had not liked what he had seen. The mixed economy which he endorses is intended by him as a safe environment in which a sensitive person can make his way without loss of dignity or fear of humiliation. Whether the middle ground can indeed provide a guarantee of acceptance without stigma is, however, by no means certain. Perhaps nothing can. Market values are a hard task-master. They are, potentially at least, a much greater cause of spoiled identity than the need to submit to a means test as the price of entry into welfare. The low-paid have behind them a sad history of relative failure in areas ranging from competitive schooling to competitive status. They will in an acquisitive society be aware of comparative deprivation in the selfdefining activities of earning and spending. They will have little familiarity with employee consultation, security of tenure and the meaningful use of ‘please’. They will return to the world of those unable to pay for the median lifestyle once their ulcers (caused by repeated rejection in the market sector) have been patched up (through the free-on-demand universalism of the National Health). Continuous winnowing can wear down the ego. It is by no means certain that a person marked down since school by commerce will actually experience a significant increment in stigma if asked to pass (in the sense of fail) an income test as the precondition for a rent rebate or an exemption from the prescription charge. Titmuss in his published work never directly addresses the issue of market-sector stigma. His unpublished lectures, on the other hand, reveal a profound sympathy with those who registered for the ‘good

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life’ and ended up as clients of the Welfare State instead. The following is especially evocative of what it means to be ‘the man or woman who is “too old at 40”’, ‘the people who are retired from work in the interests of promoting success for other people’, ‘the applicant without the “right” trade union ticket’, ‘the boy who has been to an approved school’, even ‘the girl who is unpresentable’ in a marriage market that values looks: The price of increasing specificity in selection – at school and in work – is the creation of more and more social ‘ineffectives’ – people who are rejected and who know that they have been rejected. The risk of their becoming dependent people requiring income-maintenance, medical care, psychological help and other services, increases as they become aware of their ‘ineffectiveness’ and the reasons for it.5 Here, clearly, it is non-welfare costings that inflict the stigma, the welfare services that arrive post festum to do good. The man or woman who will never work again at 40 will presumably not welcome a personal means test prior to receiving long-term benefits. The pinprick is pain and pain is bad. Even so, the ‘ineffectives’ and the rejects will almost certainly think that is the market test and not the welfare test that has done the most to make them feel deficient.

The market can cause stigma. So too can the consumption of welfare. The means test is not the only way in which the social services can make the dependent feel that an approach to the State is an admission of defeat. Society values people who can look after their own. People value themselves because they can cope without help. Pushed by neighbourhood sanctions and pulled by the conscience within, people will often feel that there is something shameful about having a child taken into care, or being on the dole, or having to ask for a cold-weather supplement where the alternative is hypothermia or malnutrition. Dependency rather than equivalency is for most responsible adults a psychological diswelfare at the best of times. The lower occupational groups, Peter Townsend observes, are especially sensitive to the implication that handouts are the symbol of default: ‘There’s much more inclination among the working class to have individualistic explanations for poverty and to imagine that

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people are poor because of personal mismanagement rather than the institutional structures of society.’6 The subjective perceptions are not those that Titmuss himself would have been able to validate. Even so, if the vulnerable do in fact feel damaged by failure and humiliated by dependency, then that is the attitudinal capital that the middle-class sociologist must acknowledge to be their own. Ann Davis, probing into the actual attitudes that exist in a mixed society where welfare speaks Latin while commerce speaks Greek, reaches the conclusion that contact with the caring services can ‘undermine self-esteem and confidence. It can reinforce the oppression experienced by the poor in our society’.7 Welfare alleviates stigma – since the lot of the poor would have been even more disgracing had they remained unable to pay for a socially acceptable standard of housing, food and clothing. Welfare also imposes stigma – since people socialised to rank themselves by what they have achieved can feel that the nexus is a sub-normal one where no return gift is expected or made: Exchanges of this kind take place in a society in which success, status and reward are represented as the fruits of individual effort and responsibility. Standing on one’s own two feet and looking after oneself and one’s dependants is portrayed as the way in which the responsible citizen behaves. Contact with a social work agency is a public declaration of failure to make the grade as a citizen. To look to a state service to supplement or substitute for one’s own efforts is to be branded as an inadequate.8 The socialist will postulate a right to welfare and the Fabian will table facts on occupation and need. At the end of the day, however, it must be the clients who make sense of the labels. If Davis is right in her contention that the poor feel second-rate because of access, then the fact must be recognised that the receipt of welfare as well as the lack of money can in their eyes be a benefit that is also a cost. The problem, as Robert Pinker points out, is that one central value-system will find it difficult to reconcile the two contradictory sub-systems of the quid pro quo on the one hand, the unilateral gift provided free of charge on the other. Pinker presents his argument in the language of learning and development:

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As we grow up, the most authentic rights we acquire and exercise are those we use in the roles of buyers and sellers in the market-place. We do not have to be persuaded that we have rights to what we buy. The idea of paying through taxes or holding authentic claims by virtue of citizenship remains largely an intellectual conceit of the social scientist and the socialist. For the majority the idea of participant citizenship in distributive processes outside the market-place has very little meaning. Consequently most applicants for social services remain paupers at heart.9 On the one hand business, on the other hand support – Pinker does not regard the two contestants as equally matched and has no doubt as to the sub-system that will engender the dominant response. Where applicants, ‘paupers at heart’, are unconvinced as to their inalienable rights and unaware that citizenship alone has given them an unquestionable entitlement, there would seem to be a strong case for an education in welfare. As applicants discover that all social classes are including themselves in state-provided benefits, as applicants find out that they are de facto the innocent victims of social costs borne by the few so that the many can prosper, the hope would be that the social services would lose their association with stigma and sanction. Titmuss (who had little sympathy with propaganda of any kind) would probably have had mixed feelings about formal lessons in community and fellowship that could all too easily degenerate into a gerrymandering of consensus. Learning from experience was, however, a different matter. Universalist services like the NHS were the supply that reinforced the demand that had created them. They were the comprehensive schools that made men and women progressively more comprehensive over time. A socialisation into socialism can challenge the sensation of stigma. So, importantly, can the quid pro quo. The Beveridge Report in 1942 had implied that the dependent would always feel neglected and undersupplied as long as the link between welfare contributions and welfare entitlements was not made transparent to them: ‘The citizens as insured parties should realise that they cannot get more than certain benefits for certain contributions [and] . . . should not be taught to regard the State as the dispenser of gifts for which no one needs to pay.’10 The Beveridge Report had also maintained that citizens, taking pride in their ability to earn life for their own,

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would actually welcome the opportunity to buy a right: ‘The insured persons themselves can pay and like to pay, and would rather pay than not do so.’11 Disappointment stigmatises. Something for nothing stigmatises. Welfare is good, the Report had said; but still the unspoiled self-image could usefully be protected by a pragmatic appeal to the in-state quid pro quo. Titmuss had read the Report and thought deeply about guilt. The following statement from 1969 shows that, in respect at least of superannuation, he could write as if a prudent shopper and not a new immigrant or an abandoned wife: ‘People do not want to be given rights to pensions, but . . . want to earn them by their contributions.’12 Titmuss tended as a general rule to ignore the possibility that unilateral transfers may themselves come to represent stigma. If, however, his 1969 declaration is a good description of people’s psychology, then there may in fact be a socialist case for hypothecated taxes, contributions-records and user charges precisely in order to signal to welfare applicants that they are more than might-havebeens begging to be let in. Titmuss’s core position on universalism and overlap effectively rules out the privatisation of the welfare services. Titmuss’s high valuation of equal self-respect, on the other hand, arguably leaves the door open to the in-state compromises of league tables, internal markets and welfare vouchers. Accent, demeanour, dress, selfconfidence all deter Henry Dubb from seeing the hospital consultant as a family friend, from standing up to the headmaster who says he knows best. Economic sanctions will not resolve the cultural gap. What they might do, however, is to attenuate the stigma that is the free gift of passivity without a contract. The private shopper buys in a second Harley Street opinion and transfers his business from Eton to Harrow. The welfare client has no analogous opportunity to establish a right to a service by virtue of the payment that he makes. A socialisation into socialism might help over time to combat the sense of personal failure that is experienced by Pinker’s ‘paupers at heart’ when they take without giving. So, however, might a greater reliance on the in-state freedom to choose.

Welfare per se can be a stigmatising encounter. Individual services themselves can be a further cause of lowered self-esteem. Thus social work can be perceived as a disempowering intrusion where a

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meddlesome outsider feels a worn overcoat to determine if it warrants replacement, scans the sideboard for expensive drinks and inspects the children for signs of physical or sexual abuse. Strangers decide in secret on the nature of ego’s need. Large-scale bureaucracies appear inflexible, oppressive, impersonal, unresponsive. Practice variance and intrinsic discretion make the client vulnerable to the whims of a single named paternalist. Disputes and adversarial relationships are a cause of anger, apathy, hopelessness, rejection. Media references to ‘dysfunctional families’, ‘unmarried mothers’, ‘welfare scroungers’ reinforce the feeling that the social worker would not be visiting if the client were able to lead a normal life. Social work can make a valuable contribution to the welfare of the at-risk. The present point is not, however, a point about contribution but a point about stigma. Social workers ask questions about life style. At least the means test only asks questions about means. Council housing too can be perceived as marginalising welfare, as welfare that provides a roof but also, in Crosland’s words, ‘a taint’ – ‘a whiff of the welfare, of subsidization, of huge uniform estates, and generally of second-class citizenship’.13 The middle classes can escape the ‘taint’. The less privileged find it more difficult to ‘go private’. Surrounded by neighbours who are themselves less privileged, told they cannot keep pets or choose their own colour scheme, the separateness and the difference can easily inculcate in them a sense of lower self-worth. This, as Crosland stressed, is difficult to reconcile with the socialist objective of levelling through services: ‘Judged in this wider sense of social status, the council tenant and the owner-occupier are by no means equal.’14 Miller writes as follows about stigma within the framework of welfare: ‘Stigma threatens the person stigmatized, the programme, and the society which condones stigmatization . . . A stigmatized clientele stigmatizes a programme: a stigmatized programme stigmatizes its clientele.’15 A means-tested university scholarship would not be a good illustration of the self debased through association with service. A council flat offered to a candidate on supplementary benefits would be a better illustration of Miller’s vision of the less-glamorous tarnished by the less-prestigious. Where problem families make a rough development a no-go area at night, where only problem families are desperate enough to brave the drug-dealing and the vandalism, it will not be the entry barrier of the means test but rather the place of residence that will have the more

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stigmatising properties at the parents’ evening or when applying for a job. Education is a further area of welfare that can damage and depress. Titmuss, leaving school early, had at least escaped the rank in the year, the struggle to score well, the class of degree – and, of course, the ever-present anxiety that the young person will be found to be academically ungifted: ‘I was not forced to learn through a system of book-memorisation for examinations. In fact, I have never sat an examination in my life. So I was never conscious of being selected or rejected for a class of élites or professional experts. I escaped – at any rate at this stage in my life – the sense of being a failure; of being a second-class citizen.’16 So vivid is this evocation of stigma through schooling that the reader confidently expects Titmuss to make common cause with Crosland in attacking the 11-plus streaming system that was in use in his adult years to separate the intelligent from the duffers. Titmuss as it happens seems never to have made up his mind on this vital topic in British social policy. On the one hand he knew that testing could be a cause of second-bestness, self-perceived, at an impressionably early age: ‘Apart from the problem of education as the road to success there is the danger here of creating more rejects. The unfulfilled promise of child justice. Disappointed parents. The sense of inferiority in the mind of the child. Labelling children as failures.’17 On the other hand he knew that the social consensus wanted the high living standards that were made possible by meritocracy and accomplishment, and that nepotism and favouritism would be even less acceptable than credentials and ratings: ‘Of course, in the world in which we live we have to have some relatively objective tests for selection and promotion . . . But is it inevitable that examinations of the formal, traditional, written type should come to dominate our whole education system and our lives?’18 Titmuss never answered his own question. Nor did he make himself the champion of the comprehensive school with the argument that the alternative could only be an unwarranted incidence of spoiled self-esteem. Significantly, however, he did recognise that schools, like markets, are filtering mechanisms which screen out the losers before handing out the prizes. Schools to that extent are most definitely a part of the Welfare State that possesses the power to stigmatise. They can do so even in the absence of the personal means test that figures so prominently in Titmuss’s theory of welfare without clients getting hurt.

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The case for positive discrimination rests on the theory of spoiled identity. Positive discrimination means the direction of resources without stigma towards a particular group or area. Here the question is not (as it is with a means test) of whom to exclude but (within the common structure of universalism) of whom to include more intensively. Whether this can be done without stigma is another matter. Some categories might feel stigmatised precisely because they have been selected: there is no a priori reason to think that the residents in Plowden’s Educational Priority Areas do not experience a collective sense of shame when they read in the newspapers that they have been branded as especially deficient. There may also be a conflict between economic necessity and the welfarist ethos where teachers and doctors in deprived areas must be paid a ‘dirty jobs’ differential to attract them away from comfortable areas rich in articulate professionals. Such differentials, necessary though they may be to secure and retain scarce welfare staffs, can be a source of profound discouragement to the local consumers should they learn the percentage value of their perceived inferiority. Again, just as some groups may feel stigmatised by being admitted, so other groups might feel stigmatised by being turned down. If a university discriminates in favour of blacks and browns, it is by definition discriminating against yellows and whites; and those latter trait-bearers, statistically good performers, might deeply resent the inference that their colour or social background is an acceptable reason for them to be denied equal access on the basis of equal worth. Even the clever and the assiduous, and not just the have-nots, can experience a sense of being left out. A compromise would be to rely, with Crosland, on rising social welfare budgets paid for out of a rising national income: then the skewing of access would only relate to the rate of increase and the discrimination against success would be tempered by the absolute improvement in opportunity. Even so, cost must always impose a cap – and necessitate a choice. Selective discrimination does not guarantee that reallocation will proceed without stigma. Nor does it ensure that the reallocation itself will be finely tuned and targeted. Where the deprived are concentrated in favelas, slums and urban disaster areas, the geographical standard in the sense of Plowden may be an acceptable proxy. Where, however, the in-need are scattered throughout the entire population (the case of the elderly, who, moreover, benefit little from the construction of new schools in the Educational Pri-

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ority Areas), the geographical test only picks up a sub-set of the deprived; and discrimination on the basis of other broad categories is susceptible to perversity. Without the use of the personal meanstest it is impossible to distinguish a poor white from a rich black, a stock-broking mother from a stock-taking mother, a rentier pensioner from a £100 pensioner. A mistake as to which person most needs the help both frustrates the objectives of social policy and spoils the identity of the citizen called invisible because he lives in the dark.

Some rejection is a fact of life. Supportive friends, a happy family, a daily swim, an absorbing hobby, a meditation class all help to insulate the ego from the bruises and slights of external assessment. Insecure people should steer clear of invidious comparison. Ambitious people should not overcommit their self-definition to risky relativities. At the end of the day, however, Romeo will choose Juliet because Ethel ‘is unpresentable’, Jack will be given accelerated advancement and Jill will be given early retirement, Dubb will be offered a kidney transplant while Higgins will be ‘too old at 50’. No sensitive person wants to be turned down or sent away. Market or state, however, some rejection is a fact of life. Titmuss writes as if some rejection were all but the same as ‘spoiled identity’. A more moderate view would be that the greater hurt can result from the lesser harm but that losing a battle need not mean losing a war. Miss Havisham did not feel better after a good night’s sleep. Other people do. Titmuss also writes as if the salience of failure is necessarily a regrettable disability. Sometimes it is – and sometimes it is the precondition for social well-being. Thus the competitive market is by definition a profit and loss system. While luck undeniably contributes much to success, so do the consensually valued character-traits of hard work, deferred gratification, self-restraint, responsible prudence that are at the heart of consumer-led supply and of macroeconomic expansion. Malthus was insistent that necessity is the mother of invention and that the fear of failure fulfils a vital function: ‘The savage would slumber for ever under his tree unless he were roused from his torpor by the cravings of hunger or the pinchings of cold.’19 People want to have more. They also want not to have less. So long as the incentive is real and the threat a credible one, it is the contention of market-oriented individualists such as Malthus that the nation as a

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whole will make a gain in socially valued affluence and activity not in spite of the incidence of failure but rather – pour encourager les autres – because of it. Titmuss was never clear what kind of economy he wanted to see. If he wanted the competitive market, then he would have to accept that some rejection is the order of the day. As with market, so with welfare. Titmuss was reluctant to meanstest the needy or to look too deeply into the past causes of distress. Alfred Marshall, demanding that relief should be channelled more and more to ‘those who are weak and ailing through no fault of their own’,20 less and less to ‘the idle and the thoughtless’,21 was more prepared to demand the facts: ‘Being without the means of livelihood must be treated, not as a crime, but as a cause for uncompromising inspection and inquiry. So long as we shirk from the little pain that this would give, we are forced to be too kind to the undeserving, and too unkind to the unfortunate.’22 Even harsher was the verdict of the Poor Law Report in 1834 – that only the hardship and the shame of wretched life within the workhouse could establish for sure that the dependent had genuinely reached the end of the road: ‘Every penny bestowed that tends to render the condition of the pauper more eligible than that of the independent labourer, is a bounty on indolence and vice.’23 Richard Titmuss, calling for compassion as an entitlement, was explicitly critical of the earlier Benthamites who, using terms like ‘deserving’ and ‘less eligible’, had sought to make the deterrent of stigma a part of the system. The danger is that, in trying hard to be kind, he may have bent the bent rod too far in the opposite direction of licence, freeridership and even cynical abuse. The scheming minx becomes a teenage mother in the knowledge that the State will give her a house and pay her an allowance. The perpetually unemployed collect their doles and their rebates on the way to the black economy or to the pub. The economic migrant pretends that he was persecuted by the police when the truth is that he is merely dying from malnutrition. Titmuss shows little interest in perversions of welfare such as these. There is in his work no acknowledgement of a dependency culture, no recognition that relief can create the distress it was intended to alleviate, no concern that bad Samaritans might exploit the generous because the kindly will be seen as an ‘easy touch’. Were he to have spent more time in the tabloid Sunday’s rogues’ gallery of wastrels and scroungers, he might have concluded that the moderate stigma of means tests

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and cross-checks was no more than was reasonable to defend socialist sharing against self-centred greed. Titmuss said little about abuse. There was a reason for his reticence. Most people, he believed, were decent, thrifty, conscientious and honest. It would in the circumstances be both mistaken and insulting to bracket the hard-working family man who loses his job with the tiny minority of twisters and con-artists who dwell on the periphery of every social order that has yet been invented. Perhaps people in Titmuss’s generation were reliably brought up to contain their selfish opportunism. Perhaps Titmuss simply preferred to concentrate selectively on the brighter side of human nature. This at least may be said with confidence: the severest criticism of Titmuss on selection without stigma is that it would be easier to realise in practice if every man were a Titmuss.

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7 Universalism I: Social Costs and Social Benefits

Economic growth is not a problem in economics alone. Titmuss regarded it as deplorable that excessive compartmentalisation had caused the community to neglect the interaction between economic and social policy. Such neglect is a serious matter since there is in fact a ‘fundamental conflict between welfare and economic growth, between economic and social growth’.1 Recognising the conflict, a collectivity that wants rising standards of living but does not wish to be unjust must therefore be prepared, first, to compensate those of its members who suffer from the social disservices, diswelfares, disutilities and insecurities that result from progress; and, second, to erect that valuable shared infrastructure of essential services which is complementary to growth in the private sector but is not provided by it. This chapter will examine these two reasons for the provision of social benefits to cover social costs in the social and economic thought of Richard Titmuss.

Consider first the need to compensate citizens for social diswelfares suffered on behalf of the collectivity. An illustration would be enforced unemployment or compulsory mobility (occupational and geographical) in a fluid economy. Technological and scientific advance brings, it is generally conceded, great benefits to the group; but it may also mean that some people are made redundant by automation and driven into early retirement because they have the misfortune to possess (through no fault of their own) obsolete skills in a world of extensive division of labour, labour-specificity and often of long retraining periods. Such redundancies (such collectively manufactured social costs) are not likely to be randomly 113

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distributed, but are likely to be analogous to a regressive tax which is a greater burden on poorer than on richer households. They in that way promote social inequalities. The groups most vulnerable to unemployment are, after all, more likely to be the poor, the unskilled, the non-white, the underprivileged, who can least afford to pay the costs of social change. Other kinds of social diswelfares may be more diffuse. This is the case with the problem of unmerited handicap (the handicap of, say, deprived children of low-income mothers; or the objects of ethnic and religious prejudice; or the ‘victims of the mistakes we make in our educational systems by wrongly stigmatizing and rejecting people as “failures”’2). This is the case too with the problem of the aged once urbanisation and the breakdown of kinship ties have led to changes in family life such that children no longer accept the responsibility for their parents. Lengthening of life-expectancy at the same time as the institution of smaller families means that parents would in any case have fewer grown-up children to rely on in the dependency created by old age. Nor should the community ignore the subjective dimensions of social costs. The worker disabled for life in a factory accident or by an industrial disease will suffer from loss of status as well as loss of earnings, not least if a career housewife must then go out to work in order to make ends meet. The man of 50 who is made redundant and is unable to obtain another job will suffer from reduced earning and spending power and from spoiled life chances, but also from a sense of failure generated in the market sector: Have we really any conception of the psychological effects on people of a continual process of social rejection and exclusion? Yet economic growth tends continuously to build ever higher these gateways to life and freedom of choice, and to widen the area over which credentialism rules; the crowd outside finds it harder to clamber over, squeeze through, or look over the top.3 Loss of status can be ‘a serious injury to the personality’,4 and yet such stigmatisation is an increasing threat (at least for the labourer) in the modern economy: The dominating characteristics of industrial conditions in the West during the past few decades have been, from the point of view of the worker, irregularity and impermanence. Unemploy-

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ment, short-time working, the decay of skills as a result of technological change, and the rationalization of production have all spelled, in the worker’s psychology, irregularity and uncertainty.5 In the modern economy, there is greater opportunity not only for individual failure but for the consciousness of individual failure. The incidence of both the fact and the perception is likely to be greater among the low-paid than among the meritocracy. Yet both social groups are expected to give the same sense of security and hope to their children. The reference to children is a reminder that the secondary effects of social change may be delayed, and that material and psychological casualties may not become noticeable for several generations. An illustration would be a society about to industrialise: If those who are first subjected to industrial change have had stable childhoods within a coherent, meaningful social order, then they may be able psychologically to withstand the pressure of change. Their children and grandchildren may be more likely to show the psychological effects of the long-drawn-out processes of industrialization. They will have been reared in an unstable culture by parents without a sure sense of direction or purpose.6 Similarly, such instability may result from bad housing and bread-line incomes in an environment characterised by the social neglect which results from generations of laissez-faire liberalism. Here it is the group rather than the individual who is to blame: ‘The devil in this particular piece seems to have more of the character of Bentham than of Freud.’7 In discussions of social time, the period in question can be very long, as is shown by the British experience in the Second World War. The stunted condition and neglected state of many of the young evacuees of 1939 were due not only to unemployment and poverty in the interwar years but to the First World War as well, for it was then that the parents were young. In the years from 1914 to 1918, many children were employed for 30 or even 40 hours per week in addition to their schooling, and others left school altogether to take up jobs. Then, on top of this exhaustion and ignorance, there was a lack of medical attention as more and more doctors and nurses became involved in the war effort. Finally, the absence, disablement or death of the father in the war is likely to have affected the emotional growth of the young.

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Similar points must be borne in mind when the delayed effects of the Second World War are added up. There is, for example, the position of ‘children who, because of the closing down of clinics in some areas or their absence in others, were left at the end of the war with uncorrected squints’; and of ‘children stigmatised – perhaps for life – as hereditarily “backward” because of the disorganisation of their schooling during the war’; and also of ‘mothers left with pelvic damage after childbirth as a result of the effects of the war on the maternity services’.8 When it is recalled that many of the children stigmatised by the Second World War were the children of parents stigmatised by the First, it becomes clear that social costs may be cumulative and also that the relevant timespan or accounting period can be lengthy: tomorrow’s dependencies may easily be the result of yesterday’s changes in life chances. Nor can society ever expect the final reckoning to be presented in terms of a set of precise estimates: The biological cost of any war, let alone war on civilian society, can never be summed up with any finality. There are the men and women who are maimed and prevented from marrying, the children who have died because of a worsening in their physical environment, the adolescents who have contracted tuberculosis for some reason arising from the war, the babies who have not been born and cannot now be born, and all the defects and injuries, subtle and gross, which one generation hands on in irrevocable fashion to succeeding ones.9 Whether material or psychological, whether currently generated or the heritage from the past, society must recognise that the costs of change cannot be allowed to ‘lie where they fall’. Social action is inescapable to compensate the victims of change once it is understood that the casualties are not simply the fault of individual action but are at least in part the necessary diswelfares that the individual suffers in order that the group as a whole might thrive. Often those whose own life chances are damaged are ‘the social pathologies of other people’s progress’;10 and society as a group must collectively choose, once it has become aware of the ‘social theory of causality’11 (analogous to the germ theory of disease) to relieve those struck down by the ‘modern choleras of change’.12 The point is that social causes indicate a need for social treatment, and that the free-market solution of allowing social costs to lie

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where they fall is not only inhuman but inconsistent. Since it is society which receives the benefits, it is society which ought to pay the bill. Because a substantial part of social welfare provided by the State ‘represents some element of compensation for disservice caused by society’,13 the redistribution associated with such welfare need not represent ‘betterment of condition’ or ‘net lessening of inequality’. It might simply mean the restoration of the status quo ante: The emphasis today on ‘welfare’ and the ‘benefits of welfare’ often tends to obscure the fundamental fact that for many consumers the services are not essentially benefits or increments to welfare at all; they represent partial compensation for disservices, for social costs and social insecurities which are the product of a rapidly changing industrial-urban society. They are part of the price we pay to some people for bearing part of the cost of other people’s progress.14 Such a price is not redistributive but anti-redistributive. The State simply redresses a previous grievance. Since much of welfare is outright compensation, it is important for it to be both non-stigmatising and non-judgemental. As regards stigma, it would clearly be grossly unjust to insult the victim of social change by means-testing him to see if he can afford to bear the cost of other people’s progress. Even if stigma were not an evil in its own right, any satisfactory means test would therefore have to distinguish cause of need as well as ability to pay once a state of dependency had been identified. Understandably, because science is not up to disaggregating the complex causes of a given dependency (causes which may to a considerable extent be shrouded in the mists of time), there is a strong presumption that no means test can ever be truly just. Again, there should be no judgemental basis for provision of welfare to those in need. It is vital to be tolerant and not to express an anti-sociological value-judgement by branding some people as ‘problems’: ‘Labels may be fashionable in a century of science, but when they attach and imply hypothetical inferiorities – of race, religion, “intelligence” or behaviour – they are fundamentally undemocratic and – in the present writer’s view – harmful.’15 A mere reference to social deviation implies, by virtue of the very words that are used, an undesirable value-judgement: ‘Language is not a mere symbolic

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tool of communication. By describing someone as deviant we express an attitude; we morally brand him and stigmatise him with our value judgement.’16 Such a judgement is unscientific and incorrect, since the deviant might not be deviant in their essence but merely deviant because of the social situation in which they find themselves. Titmuss states categorically that ‘social deviation, like crime, is a social ill or a “social problem”’,17 a social fact to be explained by other social facts. Here we see the justification and role for truly social policy. In the case of poverty, for example, the causes may be collective rather than individual. It is therefore regrettable that we have so often in the past ‘sought too diligently to find the causes of poverty among the poor and not in ourselves’.18 In the past, our frame of reference has been too narrow and ‘poverty engineering has thus been abstracted from society’.19 In the future, we should adopt a more sociological approach to social policy, and attempt to grasp that the diseconomies associated with economic growth may well engender social rights to compensation. It would, of course, be wrong to think that such compensation can be precisely assessed, particularly since the costs of progress may be psychological as well as material. Here as elsewhere in the social sciences, accurate calculations are an abstraction. Here as elsewhere, however, the quantitative also tends to push out the qualitative until we find ourselves ‘saddled with a new form of Gresham’s Law: monetary information – or dollar number magic – of lesser significance tends to displace other information which may be of greater significance’.20 This tendency is dangerous. The fact that damages cannot be assessed exactly does not mean that society should neglect to compensate its victims. The problem of social costs will become more acute in the future due to the acceleration of economic, social, scientific and technological change. It is therefore unfortunate that economists ignore these costs when they make their calculations: The social costs of change rarely enter into the calculations and models of economists. They measure what they can more easily count. As yet, we cannot quantify in material terms social misery and ill-health, the effects of unemployment, slum life and Negro removal, the denial of education and civil rights, and the cumulative side effects from generation to generation of allowing cynicism and apathy to foster and grow. These are some of

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the costs which appear inescapably to accompany social and technical change. They are not embodied in any index of ‘real’ income per capita. We have, therefore, to remind ourselves continuously about their reality, partly because we happen to be living in a scientific age which tends to associate the measurable with the significant; to dismiss as intangible that which eludes measurement; and to reach conclusions on the basis of only those things which lend themselves to measurement. Mathematical casework is not yet, I am glad to say, on the horizon.21 Consider now the second reason for the provision of social benefits to cover social costs, namely the need to supply essential services complementary to growth in the private sector but not provided by it. To some extent this follows on logically from the need to compensate the victims of change: in a number of cases, after all, society has been forced into paying the costs of change by the fact that alternative compensation has simply not been forthcoming. One of the principal reasons for the State’s acceptance of the obligation to compensate (in cash or in kind) for income loss or other injury to life chances is the fact that ‘scientifically, statistically and legally, it is becoming increasingly difficult in all modern societies – capitalist, socialist or mixed – to identify the causal agents of diswelfare and charge them with the costs’.22 Social costs cannot be shifted back to the causal agent where the culprit cannot be found, and hence the costs are transferred on to the State: ‘Nondiscriminating universalist services are in part the consequence of unidentifiable causality.’23 The alternative to social provision is to allow the costs to lie where they fall. Redress of grievances through the courts is expensive, complicated and inadequate. This is only to be expected in an increasingly complex society where it is easy to identify neither the tort-feasors nor the victims of change. The difficulty increases with the passage of social time (where pathologies accelerate and become cumulative so that today’s dependency may date back to a cause two centuries ago). Nowadays causality of disservice is often multiple and so diffuse as to ‘defy the wit of law’.24 In such a case there is no alternative to State welfare provisions since private fault cannot be established: Can we, in providing benefits, distinguish between ‘faults’ in the individual (moral, psychological or social), the legal concept

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of ‘fault’ in private accident insurance, and the ‘faults’ of change? Put concretely, can we say when a coal miner living in a slum house contracts tuberculosis and needs medical care plus income maintenance for himself and his family, that the mine owner in the past or the National Coal Board today is responsible, or the landlord of the house, or the man himself or the whole community?25 The inability to assign ‘fault’ suggests that ‘fault’ itself might be non-specific in origin. Where this is the case, a diswelfare seeming to result from individual initiative might in fact have a wider social cause. Witness the incidence of road accidents: ‘During this century more people have been injured by the automobile in the USA than in all the wars that country has been engaged in – the First World War, the Second World War, the Korean War and the Vietnam War.’26 Looked at from one perspective, the car industry seems to impose a heavy cost on the community: ‘In Britain in 1965 there were nearly 400,000 road casualties, one-quarter of them classified as “serious” and demanding prolonged hospital care.’27 Looked at from another perspective, however, the motor car may be thought of as part of a way of life, so that it is that amorphous way of life which is ‘at fault’. The existence of road accidents does not necessarily make the car industry guilty, or mean that it ought to contribute towards hospitals and insurance benefits (despite the fact that at present in Britain about half of road accident victims must rely on state compensation in the absence of any court awards at all).28 Again, to take another example, there is the instance of the firm that goes bankrupt because it produces out-of-date commodities in a rapidly changing economy. Such a firm should not have to pay unemployment compensation or finance the retraining of workers with obsolescent skills any more than the injured party should have to go without. Here there is simply no ‘guilty’ party needing to make amends for economic and social change. It is worthwhile remembering too that a bankrupt firm, even where as guilty as original sin, does not typically have the means to pay damages. This example, like that of the motor cars, illustrates how the two reasons for state provision of social benefits to cover social costs may in practice converge. Not only does the problem in each case have a social cause (implying the need for social compensation), but private redress is in both cases unreliable and inadequate

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(indicating the complementarity between state provision and private activity). Many are unaware that social growth, rather than inhibiting econ– omic growth, is actually complementary to it. Yet the truth is that there is no necessary contradiction between compassion and efficiency, since welfare can make a ‘positive contribution to productivity as well as reinforcing the social ethic of human equality’.29 The social services are thus an important part of the life of the community: ‘They are an integral part of industrialization.’30 Titmuss had occasion to draw the attention of the Government of Mauritius to the handmaiden role that could usefully be played in the process of economic development by a national health service: Both the incidence and duration of periods of incapability for work can be reduced. If there were better preventive services, there would be less illness. If there were better curative services, there would be a swifter return to work. If there were better rehabilitation services, there would be less economic waste and less drain on the medical and public assistance budgets. If the maternity and child welfare services were improved, the women of Mauritius could bear healthier children with fewer debilitating pregnancies and employers would benefit from a new generation of workers with a greater output and more regular attendance at work.31 A national health service is a valuable external economy to employers. This is borne out by the British experience: ‘It is estimated that in industrial areas in Britain today up to one-third of all hospital out-patient attendances are attributable to factory accidents . . . These are social costs of production which have been transferred – so far as medical care is concerned – to a “social service”.’32 In many such cases, the causal agencies are known. For example: ‘Men employed in the chemical industry are about thirty times more likely than the general population to die of cancer of the bladder.’33 Yet Titmuss does not call for the guilty to provide better compensation, and points instead to the present state of neglect: ‘For an individual worker the connection between the medical diagnosis of cancer and the nature of his employment and contact with the causal agent may never be made or made too late. The worker, his widow and children will thus have been denied industrial disease benefits and legal compensation.’34

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The chemical industry lives on social welfare. So do the multinational giants who supply the cars. Titmuss gives the example of motorways, parking spaces, town planning, slum clearance, meters, traffic police, driving tests, hospitals and insurance benefits supplied in the state sector because of private-sector accidents and air pollution caused by fumes. These products and services are complementary to the motor car, but are provided free of charge by the community. The reason is market failure, that only the State is in a position to deal in these benefits: How should these positive, correcting, preventive, and compensatory services be paid for, and who should be responsible for providing them? They cannot be bought and paid for in the private market by the individual motorist. They cannot be insured against in the private market. There is no monetary profit in the provision of anti-air pollution services, for instance.35 In the absence of state action, in a situation where private costs seriously diverge from social costs, the result is all too likely to be no action at all.

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8 Universalism II: Integration and Involvement

Richard Titmuss believed that ‘it is now (or should be) an objective of social policy to build the identity of a person around some community with which he is associated’.1 This integrative objective ‘is an essential characteristic distinguishing social policy from economic policy’.2 The market mechanism is too individualist to conceive of the organic and neglects the vital importance (both positive and normative) of harmonious community relations and a sense of involvement. It is clearly not suitable for a subject such as social administration – of which the ‘primary areas of unifying interest are centred in those social institutions that foster integration and discourage alienation’.3 Titmuss warned the Government of Tanganyika that the decline of traditional local communities might lead to a moral vacuum, a state of Durkheimean anomie characterised by excessive individuation and an absence of satisfactory relationships: Towns and villages which have been long established have, like the houses of which they consist, often developed characteristics which favour the maintenance of a satisfactory community structure within them. This is, however, seldom the case in rapidly growing villages and towns, many of which have in other countries suffered not only the ravages of communicable disease, but the breakdown of community life and the substitution of an amorphous group of which the members admit responsibility to no one, with consequent deterioration of ethical and legal standards and the spread of mental distress.4

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This tragic picture of aloneness must be contrasted with the healthy spectacle of togetherness presented by the example of Britain at war. Then opportunities arose to play an active part in the community and brought people closer together, overcoming moral isolation and preventing any mass breakdown of mental health despite long periods of almost daily bombardment and the threat of invasion. Titmuss, in one of his most evocative passages, writes as follows of the externalities and the energies that Hitler’s bombs had liberated from their lethargy: The civilian war of 1939–45, with its many opportunities for service in civil defence and other schemes, also helped to satisfy an often inarticulate need; the need to be a wanted member of society. Circumstances were thus favourable to fuller self-expression, for there was plenty of scope for relieving a sense of inferiority and failure . . . It could conceivably be argued that to some people the air raids brought security – not the security which spells passive acquiescence, but that which allows and encourages spontaneity. The onset of air raids followed a long period of unemployment. One thing that unemployment had not stimulated was an active body or mind. It might be suggested – though it cannot yet be asserted – that the absence of an increase in neurotic illness among the civilian population during the war was connected with the fact that to many people the war brought useful work and an opportunity to play an active part within the community . . . New aims for which to live, work that satisfied a larger number of needs, a more cohesive society, fewer lonely people; all these elements helped to offset the circumstances which often lead to neurotic illness.5 The ‘social and psychological sense of community’ is a broad concept, but one which may be equated with ‘the concept and consciousness of “who is my neighbour?”’.6 It is a desirable sensation, for man, a sociable as well as a social animal, is happiest when most integrated in the group. Social policy ought therefore to be seen as being concerned not simply with the relief of individual needs but with the furtherance of a sensation of common citizenship. The former function could be fulfilled by a system of cash handouts. The latter imposes the condition of common facilities and equality of access as of right, without the socially divisive stigma of a personal means test.

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Equality of access to the universalist social services contributes to social integration and combats the sensation or reality of social discrimination. Unity furtherance ought to be a major objective of a national health service, as Titmuss and his colleagues told the Government of Tanganyika: ‘We want to see a health service developing which will not be separate and aloof from the life of the nation but an expression and reinforcement of national unity.’7 So should discrimination avoidance: ‘It is now widely accepted that in all sectors of the economy there is a national need to diminish both the absolute fact and the psychological sense of social and economic discrimination.’8 Four examples relating to the National Health Service will help to make clear the socially integrative role that Titmuss imputed to the Welfare State.

First, like the state educational services, the National Health Service has ‘a community relations or non-discriminatory integrative function’9 in so far as it helps to integrate ethnic minorities. Race hatred and conflict can result from denial of participation, from felt exclusion. Welfare services make non-white people feel at home. In the United States, poor blacks excluded from the profitmotivated private medical services and forced into a sub-standard state system feel stigmatised and rejected on the grounds of colour. This dual welfare system, rather than furthering a sense of ‘one society’, 10 actually increases those tensions that arise out of powerlessness, marginalisation and shutting out. The example of the United States shows that ‘more prosperity and more violence may be one of the contradictions in a system of unfettered private enterprise and financial power oblivious to moral values and social objectives’.11 In Britain, in sharp contrast, pink and non-pink people share adjacent beds in hospital. In America, voluntary hospitals ‘have public wards for indigents which tend to be full of black people. This can be contrasted with the integrated wards and outpatient departments of British hospitals under the National Health Service.’12 Ethnic integration is fostered by the absence of formal barriers to access other than need in a system of medical care available to all on a universalistic basis. The National Health Service plays its part in combating a major social ill, racial discrimination, to which the market mechanism would have turned a blind eye. Titmuss therefore expresses the opinion that ‘civil rights legislation in Britain

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to police the commercial insurance companies . . . would be a poor and ineffective substitute for the National Health Service’.13

Second, the National Health Service provides the same treatment to manual and non-manual workers, as indeed to the retired and the unemployed. With the introduction of the National Health Service, ‘one publicly approved standard of service, irrespective of income, class or race, replaced the double standard which invariably meant second-class services for second-class citizens’.14 Here an important reason for equality of treatment and the resultant integration despite other class distinctions is to be found on the side of demand, not simply supply: ‘The middle-classes, invited to enter the Service in 1948, did so and have since largely stayed with the Service. They have not contracted out of socialized medical care as they have done in other fields like secondary education and retirement pensions.’15 It is important for the upper and middle classes to share in the benefits as well as the costs of welfare if the Welfare State itself is not to acquire the stigma of catering mainly for the needs of the lower occupational groups and of the very poor. Any de facto absence of universality may encourage redistribution but it impedes integration. Besides that, the use of the National Health Service, if it is felt mainly to be the resort of the poor and the indigent, may spoil the image of themselves that is held by the needy. They may come to think of themselves as lazy and inferior, separated by a class barrier from the more fortunate members of the population.16 The mass media have a social obligation to propagandise in favour of the Service and to show how it is being used by all groups in the community. Unfortunately, a critical stance towards the Welfare State is more often to be found.17 Bad publicity has the same effect as a means test in fostering stigma.

Third, the National Health Service reaches the hard-to-reach whom private profit-maximisers would exclude from the world of welfare. In this way the pathological cases too are integrated, via equality of access, rights and treatment, into the community of which they are a part. The problem is that many of the most needy in modern society are precisely those people with not only unmet but unexpressed needs, to be found notably

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among the poor, the badly educated, the old, those living alone and other handicapped groups. Their needs are not expressed and not met because of ignorance, inertia, fear, difficulties of making contact with the services, failures of co-ordination and co-operation between services, and for other reasons. These are the people – and there are substantial numbers of them in all populations – who are difficult to reach. Yet they are often the people with the greatest needs.18 A Welfare State with universalist services eliminates the stigma and shame that might frighten potential customers away from public provision. The fact that the services are free on demand to all citizens means that there is no financial barrier to proper treatment. It also means that the hard-to-reach will be integrated at treatment centres with a typical cross-section of the community in terms of class, race, age group, marital status and other characteristics. Moreover, since not all needs are ‘felt’ needs, a Welfare State often makes potential consumers aware of the asymptomatic and the correctable; and also of remedial services which will mitigate or obviate the unnoticed sub-optimality. Thus a general practitioner conducting a routine examination might diagnose an unmet need which cannot be articulated or self-diagnosed (perhaps malnutrition, perhaps the need for mental health services). A social worker dealing with problem A in the social security offices or in the client’s home might notice problem B, inform the potential patient of his right to a service, and reassure him that he can apply without fear of being reprimanded for wasting the professionals’ time. The emphasis in the modern Welfare State is on entitlement, not deterrence; on letting the needy in, not keeping them out. In such a system, the social worker has an educative as well as an administrative function to perform: Education, as distinct from propaganda, is about freedom; it increases awareness of possible choices. To enable clients better to exercise choice is an integral part of the functions of social work and here, it may be said, the social worker as an individual enacts an educational role which is sanctioned as such by society.19 An example of that educational role is blindness prevented. In the period from 1948 to 1962, the National Assistance Board (not the medical profession) was the principal source of referral for preventive

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action against blindness among the aged. These people were hard to reach but they had to come in for cash benefits. Even now, Titmuss writes, ‘it is possible to see two nations in old age; greater inequalities in living standards after work than in work’.20 Having nothing but their state pensions to live on, the old had to apply for national assistance; and helpful clerks then advised them to take advantage of their right to another service, a free eye test. Often the hard-to-reach have multiple needs, so personal contact is invaluable. Such a personal relationship (and not just a formal ‘paper relationship’) ‘can be the source of knowledge and information, advice and encouragement. It is also a source of freedom. Blindness prevented is an enlargement of freedom.’21 There is no substitute for human contact. Titmuss therefore rejected mechanical solutions to the problems of the dependent (such as the negative income tax) on the grounds that they are impersonal: ‘Instead of the home visit and personal contact with a caseworker there will be substituted the postal application, the computer and the postal payment.’22 Personal contact is desirable in itself (even the student revolt in the 1960s could be traced in part to neglect of teaching and communication on the part of academics). It also allows the social worker to advise the hard-to-reach (the education-disseminating function) and to identify social shortcomings (the information-gathering role). Where benefits are universal, the commitment to non-judgemental administration should clearly not be allowed to reduce opportunities for human contact. Where benefits are selective, precision of rules should be accompanied by a similar discretion of authorities in order to ensure ‘individualised justice’.23 Such a mixed model is not only more humane but more flexible than one based on unbending rules alone. It avoids the rigid ‘pathology of “legalism”’ implicit in an overcodified system ‘based on precedent and responsive only very slowly to rapidly changing human needs and circumstances’.24 In Britain, the Supplementary Benefits Commission is a good illustration of the mixed model that Titmuss had in mind. Valuing precision, it has published leaflets, booklets and handbooks to explain the rules it applies and to advise potential consumers of their options. At the same time, however, it also sees a role for discretion and believes in leaving scope for ‘flexible responses to human needs and to an immense variety of complex individual circumstances’.25 Abuse of power, naturally, should be prevented; and there

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must be checks on ‘the interfering, moralising, judgemental caseworker’.26 People should be informed of their rights and adequate appeal mechanisms should be provided. Discretion should also be made subject to sensitive quality controls, audits and inspections, collection of statistics, surveys, research. The system should be responsive to constructive criticism from outside individuals and organisations, and there should be improved training of staff. The present system has the disadvantage that A passes a moral judgement on B as a precondition for discretionary benefits (a disadvantage since, after all, human decision-makers can be biased and fallible). Yet a check on that power is deliberately provided by the fact that the official may be asked to justify his behaviour to a superior or to an appeals tribunal with greater sensitivity to current social values. The discretionary system, because it allows for personal contact at a number of points in the Welfare State, helps to ensure the more adequate participation of the hard-to-reach. Understandably, this increases pressure on resources in the same way as does the provision of benefits as of right with the minimum of stigmatising rules and regulations. Many of the needs experienced by the hardto-reach are, however, diswelfares imposed by collective change; and social integration is in any case as legitimate an end in its own right as, say, the self-seeking profit-maximisation of the private entrepreneur.

Fourth, there is the example of altruistic, voluntary gifts to strangers. This to Titmuss is an important index of social health. It is also a paradigm of what social policy is all about: ‘The grant, or the gift or unilateral transfer – whether it takes the form of cash, time, energy, satisfaction, blood or even life itself – is the distinguishing mark of the social (in policy and administration) just as exchange or bilateral transfer is the mark of the economic.’27 Through the act of giving, citizens express their involvement in, and commitment to, their community. They thus strengthen the cultural bonds of the group. As a case study of the unilateral transfer Titmuss uses blood donation and its transfusion. This he believes to be ‘one of the most sensitive universal social indicators’,28 a good index of the cultural values and human relationships prevalent in a particular society. His method is to make a comparison of systems relying on paid blood merchants with systems relying on unpaid donorship.

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One of the greatest externalities of the private market is the introduction of the cash nexus, the economist’s quid pro quo, the ‘dialectic of hedonism’29 into non-market interaction. The paid donor sells his blood for what the market will bear. He regards the transaction as impersonal and calculated, as no less commercial than any other way of earning money (to which the sale of blood may be an alternative or a supplement). The possessive individualism of the utilitarian marketplace thus stifles the spirit of giving. It drives out community-spiritedness and undermines the quality of personto-person contact. Material acquisitiveness has supplanted the spirit of fellowship in both the United States and Communist Russia. For Titmuss the index of blood donorship provided the proof. In the United States, paid donors are untypical of the population, and the blood donorship is biased towards low-income groups, the black, the male, the young, the unskilled, the unemployed, the deprived, the socially inadequate. These constitute a ‘blood proletariat’30 supplying blood to those classes who can afford to pay. Such a bifurcation indicates that the cash incentive is incompatible with the sense of community. In Russia too the sense of community must be low, since Soviet donors must be bribed to give by the promise of longer holidays, free public transport for up to a month, days off, free meals, and even the exceptionally high price of 60 roubles per litre (equivalent to, say, half a month’s pay at the national minimum wage).31 Such attractive conditions are indicative of the scarcity of blood for transfusion in the Soviet Union, but also of the low social priority of mutual aid. In both the United States and Russia, if blood is a good indicator, extensive detachment and ethical decay may be expected from the low sense of social integration: ‘Although attempts have been made to value human life, no money values can be attached to the presence or absence of a spirit of altruism in a society. Altruism in giving to a stranger does not begin and end with blood donations. It may touch every aspect of life and affect the whole fabric of values.’32 Consider now Britain, where there are virtually no material rewards in money or kind to blood donors and where blood is a free gift to unnamed strangers. In Britain, unlike the United States, the blood donorship appears broadly typical of the national population in respect of age (up to 55), sex (after allowing for the effects of child-bearing on younger women’s participation rates) and marital status (even the divorced, widowed and separated do not withdraw

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from the group and contribute their due proportions along with the married and the single, giving indeed if anything slightly more often than their numbers in the national population would have led one to expect). 33 As for social class, there may be some overrepresentation of social classes I and II and a corresponding underrepresentation of the lower classes. This is indicative not of alienation, however, but of spurious factors. Such factors would be the higher percentage of non-eligibles in the lower income groups, or the practice in institutional sessions of giving executives and white-collar workers the first chance to volunteer (the result being that the list may well be closed before the staff on the shop floor are given an opportunity to donate34). Titmuss based his conclusions on a small-sample pilot survey of some 3813 donors in England and Wales conducted in 1967. It is worthwhile noting that as many as 13 per cent of donor households studied revealed incomes of the chief earner such as that they might have been at or even below the supplementary benefits level.35 So much for the estrangement of the poor! As far as donor motivation is concerned, Titmuss was convinced that at least 80 per cent of the answers received in his 1967 questionnaire survey suggested ‘a high sense of social responsibility towards the needs of other members of society’.36 The reasons given by donors to explain their free gift included pure altruism (a desire to contribute to the welfare of others in need), social awareness (a thank-offering for previous transfusions received by oneself or a member of one’s family from unknown strangers), prospective stake (no one can be certain that he will not in future himself have need of such gifts), sense of duty (a feeling that one ought to help others), awareness of need, response to an appeal from a workmate or on the radio. Clearly, such people felt integrated in the community. They could have contracted out of the current cost without contracting out of the potential benefit (and the ideology of the private market teaches utility-maximisers to give as little and take as much as they can). That they did not do so shows that they believed in ‘man’s biological need for social relations’: ‘To the philosopher’s question “what kind of actions ought we to perform?” they replied, in effect, “those which will cause more good to exist in the universe than there would otherwise be if we did not so act”.’37 An important reason for the exemplary public response in Britain to the National Blood Transfusion Service is that it operates in

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symbiosis with the National Health Service. The 1948 system is vital in so far as it provides an institutional structure that allows for the expression of altruism: The most unsordid act of British social policy in the twentieth century has allowed and encouraged sentiments of altruism, reciprocity and social duty to express themselves; to be made explicit and identifiable in measurable patterns of behaviour by all social groups and classes. In part, this is attributable to the fact that, structurally and functionally, the Health Service is not socially divisive; its universal and free access basis has contributed much, we believe, to the social liberties of the subject in allowing people the choice to give or not to give blood for unseen strangers.38 The statement is central to the welfarist vision. There are two points in it which deserve particular attention. The first point to note is that the National Health Service and the National Blood Transfusion Service both make the assumption of universality of need. They amplify it with the further assumption that the donor will willingly forego the right to precommit the characteristics of the recipient. Blood donation is not tied in the United Kingdom, and there is no prescribed and specified discrimination in the destination of the gift. One of the principles of the National Blood Transfusion Service and the National Health Service is to provide services on the basis of common human needs; there must be no allocation of resources which could create a sense of separateness between people. It is the explicit or implicit institutionalization of separateness, whether categorized in terms of income, class, race, colour or religion, rather than the recognition of the similarities between people and their needs which causes much of the world’s suffering.39 The success of the system in stimulating individual volunteers to make free gifts to unnamed strangers demonstrates how far donors share the values of the Services. Symbolic of the network of interdependence and mutual aid that exists in modern Britain is the British haemophiliac, a person who relies annually on the free gifts of up to 50 unnamed citizens. The British haemophiliac is likely to

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have in his veins at any one time the blood of rich and poor, black and white, male and female. Blood and life are emotive areas; but so are integration and money. The second point to note is that the structural arrangements in Britain help to further good fellowship not only because the donor is not paid but also because the recipient is not expected to pay. Perhaps man has a ‘biological need to help’,40 but he will be reluctant to satisfy it by donating blood which will then be sold to a private patient at a price set by supply and demand. This restricts man’s freedom of choice (and specifically his freedom to donate), since the opportunity ‘to exercise a moral choice to give in nonmonetary forms to strangers’ is an ‘essential human right’.41 Certainly, without the existence of the National Health Service, people ‘in the relatively affluent, acquisitive and divisive societies of the twentieth century’42 would be less willing to give to strangers (persons outside the circle of family and friends) rather than to sell to them. Socially speaking, the cash payment can be a disincentive to action: ‘altruistic donors can hardly be expected to give their blood to profit-making hospitals’,43 and might refrain altogether from blood supply. In all cases a cash nexus erodes the sense of inclusion and community which a group has the right to choose for itself. Payment for blood and voluntary-donorship systems are indices of quite different social climates. It is possible, however, that the conceptual gap between them can be narrowed by drawing a parallel between free gifts in Western society and the ritual exchange of gifts in the primitive societies described by Mauss and Lévi-Strauss.44 In the ritual-exchange system the gift is neither a profit-motivated economic transaction nor a totally disinterested unilateral transfer. Rather, it is a moral nexus, one capable of ‘bringing about and maintaining personal relationships between individuals and groups’.45 Gift leads to counter-gift (so that to give is also to receive, albeit possibly after a time-lag) or at least to a socially patterned thankyou. There are social sanctions such as shame if one refuses to do what is expected. Upon inspection, however, it becomes clear that there is only one real similarity between gifts in primitive society and the gift of blood in Health Service Britain. That resemblance lies in the fact that in both cases the transaction is anchored deeply in the social fabric, in the cultural orientation of the collectivity. Otherwise, attitudes to ‘friendship and intercourse’ diverge. There is in Britain, for example, no social obligation or compulsion to give blood,

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no reward for donating nor any social sanctions (not even moral recrimination) for not doing so. There is in Britain no personal expression of gratitude (due to the anonymity of donor and recipient and the absence of the personal face-to-face confrontation that would be found in a small-scale society). There is not even a guarantee that the gift of blood will lead to a counter-gift in an unknowable future. One hopes that one will never need a blood transfusion. One has no certainty that others will in future provide the gift. One cannot be sure there will always be a National Health Service. Of course, even in Britain the counter-gift is implicit. For one thing, the very act of donation yields pleasure to the donors because they are able to transcend self-love and demonstrate their attachment to the group: ‘To “love” themselves they recognized the need to “love” strangers.’46 That is why they elected to make gifts with no economic or exchange value. Again (and this is a more sociological factor than self-felicitation), although the donors neither desire nor expect a return gift, they know that they or their family may one day be dependent on such reciprocation. This reinforces their awareness of interdependence and their sense of integration. People willing to provide blood are likely to be people confident that others will provide them with a similar gift if the gift is ever needed, and thus people confident as to the moral health of their community: In not asking for or expecting any payment of money these donors signified their belief in the willingness of other men to act altruistically in the future, and to combine together to make a gift freely available should they have a need for it. By expressing confidence in the behaviour of future unknown strangers they were thus denying the Hobbesian thesis that men are devoid of any distinctively moral sense.47 Blood donation is not the only possible index of ‘creative altruism’ (‘creative in the sense that the self is realized with the help of anonymous others’). 48 Another example, also relating to the National Health, would be the teaching hospitals: ‘To qualify as a doctor in Britain, it is probable that the average medical student now needs access to or contact with in one form or another some 300 different patients.’ 49 These patients are, because of the universality of the National Health system, drawn from all sectors of the

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population. (American doctors train and do research on indigents, with the curious implication that, the fewer the indigents there are today, the fewer the doctors there will be tomorrow.) The patients are strangers but their willingness to act as specimens is none the less ‘taken for granted in the name of research, the advancement of medical science, society’s need for doctors, the better training and more rapid progression of doctors professionally and financially and, ultimately, for the good of all patients irrespective of race, religion, colour or territory’.50 Here we have a case where the doctor (as student and researcher) and the community clearly benefit, but where the patient in the short run does not (except in so far as the latent function of his helpfulness is that he in practice benefits from more medical contact). Typically, the benefits accrue in the long run. They generally further the well-being of some future collectivity of patients. If old age pensioners with chronic bronchitis put to themselves the Hobbesian question – why should men do other than act to their own immediate advantage? – they might start charging for the gifts they make which are more likely to benefit future cohorts of chronic bronchitics.51 Yet pensioners do not charge for the gifts they make. They acknowledge their social obligation and sense of belonging by making a disinterested transfer. They thus identify themselves as members of a ‘caring community’ which also includes cooperative field and control material used by sociologists, laboratory volunteers used by psychologists, the mentally ill used by student psychiatrists, schoolchildren used by aspiring teachers. This willingness to serve the community without an immediate personal gift in return is not only a sign of integration but is indispensable to progress: ‘More and more instruments of social policy are in action requiring, as scientific knowledge advances pari passu with professionalization, these acts of “voluntaryism” which carry with them no wish for return acts or return gifts.’52 Pity the professional in a society where free gifts have become articles of commerce, since science and technology have increased rather than reduced the need for altruism. Were free gifts to become mere commercial consumables to be bought and sold, there would be no justification for not replacing all welfare services (schools, hospitals, social work, and even universities and churches) by private markets which would accord so

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much better with the eroded consensus of a broken-up community. The choice of the market would set people free from ‘the conscience of obligation’.53 Social policy would become economic policy. Fortunately, that sad point has not yet been reached. Social policy still exists because free gifts still exist, because there is still a premium on integration and involvement.

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9 Universalism III: Planned Redistribution

Redistributive policies are operated by the political authorities when they interfere with the pattern of claims to command-over-resourcesover-time that is established by the market, when they ‘assign claims from one set of people who are said to produce or earn the national product to another set of people who may merit compassion and charity but not economic rewards for productive service’.1 The government both imposes costs (in the form of taxes) and provides benefits (in cash or in kind). Redistribution occurs when the money claimed in taxes is not restored in precisely the same measure in the form of benefits to precisely those taxpayers who provided it, but is redirected instead from one person or group to another person or group. All welfare schemes are redistributive, and neutrality is not a feasible objective: ‘I do not know of any programmes in any country of the world which do not, in their total effects, increase or decrease inequalities in the distribution of income and life chances. Some benefit the rich more than the poor; others benefit the poor more than the rich.’2 The real problem is therefore not to establish that redistribution is taking place but to identify the direction and magnitude of that redistribution, and possibly take steps to plan it. It is often asserted that the British Welfare State is redistributive from the rich to the poor, and even that the burden is so excessive that the well-to-do have unfairly been made into victims. It is widely believed that taxes in Britain fall disproportionately on the welloff, while the expansion of the social services disproportionately favours the lower income groups. Titmuss, while acknowledging the egalitarian aims of the Welfare State, was not convinced that greater equality was in fact being attained. Writing in 1964, he announced 137

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bluntly that ‘the advent of “The Welfare State” in Britain after the Second World War has not led to any significant redistribution of income and wealth in favour of the poorer classes’.3 At the very most, the Welfare State had prevented existing gaps from widening in the postwar period: ‘Had social policies been less influential during these years . . . then, I believe, the trend toward inequality would have been more marked.’4 The reasons for the modest net impact of the Welfare State will become clear if redistribution is examined first from the point of view of costs and then from the point of view of benefits.

First, then, costs. Here Titmuss pointed out that the tax system may be seen in certain circumstances not as a burden but as a form of welfare. Deductions and tax allowances for life assurance, pension schemes, dependent children, mortgage interest, maintenance to a former wife may be a form of social engineering, but they are also a form of collective provision. Such tax saving is analogous to a transfer payment: it increases the taxpayer’s net disposable income at the expense of the rest of the community. In that sense fiscal welfare is similar to social welfare. Fiscal welfare often rewards rather than penalises the well-to-do. Allowances, for example, being lump-sum, are clearly more valuable the higher one moves up the tax scale. They may move a household out of higher tax ranges altogether (thereby reducing the bite of progressive income tax). At the other end of the scale, however, they are valueless to low-income families who pay zero direct tax (and whose needs might be acute where they are not only poor in income but rich in offspring). It might cost the Exchequer more to allow a citizen paying progressive income tax at the higher rates to deduct mortgage interest from his gross income than to provide him directly with a modest council flat. As with houses, so with pensions. Private pension schemes, as a deduction for tax purposes, represent a substantial opportunity cost to the Treasury and hence a major hidden subsidy from society: ‘As at present organized, the cost to the Treasury (the whole community) of private pension schemes substantially exceeds the Treasury contribution to social security pensions for the whole population. The pensions of the rich are more heavily subsidized by the community than the pensions of the poor.’5 One of the reasons for the continued preponderance of middle-

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and upper-class students in higher education (one of the highercost sectors of the Welfare State) has been the existence of a prosperous private market in secondary education; and this private market has in turn been heavily subsidised by the State through the system of fiscal welfare. For one thing, independent schools often enjoy partial charity status for purposes of taxation. Moreover, a parent is allowed a tax deduction for each child in full-time education regardless of the rate of tax paid or whether or not the child is in receipt of a grant. Also, a parent may finance a child’s education at a public school by means of a covenant. Here, since a part of the parent’s income is automatically alienated and transferred to a separate entity, so is the liability to pay tax on that income. This represents substantial tax-saving if the recipient has no income of his own. For example: ‘A married man with an income of £15 350 a year can put fully £250 in the hands of his aged and impoverished mother-in-law at a personal cost to himself of £28 2s. 6d.’6 Clearly, in the case of an educational covenant, this represents a substantial subsidy by the taxpayer to privilege, élitism, a class monopoly of graduate jobs, and even, ultimately, a marriage between two fortunes who met up at Oxford. In the case of tax deductions such as these, fiscal welfare is unambiguously redistributive. It alters the pattern of claims that would otherwise have obtained in the market, and not necessarily in favour of those households most in need of help. This suggests that a closer examination of the social effects of the tax system is needed than has been provided by those economists who have concluded, after examining Inland Revenue statistics over time, that income differentials are narrowing. It is not clear that progressive taxation is leading to greater equality. Existing statistics are misleading. They may be said in particular to ignore three important difficulties. First, Inland Revenue statistics and studies based on them are lifeless and unconvincing since they do not explicitly – or adequately – take social change into account. An increasing propensity for wives to work will, for example, mean increasing inequality of incomes in a country where husband and wife are assessed as a single unit for income tax (although, socially speaking, it will actually mean greater equality of incomes in the nation as a whole, as would be apparent if they were to be assessed separately). Again, if incomes are aggregated and more working-class wives go out to work while more middle-class wives stay at home, the income distribution table will look more egalitarian for spurious reasons unconnected with

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the bite of progressive tax. Indeed, the statistical equalisation of incomes might actually conceal a situation where life had become proportionately easier for middle-class families and proportionately harder for the poor, in that way forcing lower-class wives to take on extra work. Earlier marriage, too, may give the impression of greater equality, since many low-paid young girls thereby disappear altogether from the income-tax statistics (some of them reappearing later, of course, to inflate aggregated figures for lowpaid married couples). Finally, full employment may reduce inequality by converting the unemployed into the low-paid and thus boosting their incomes. These examples show that, here as elsewhere, statistics are meaningless by themselves and must first be integrated into the surrounding social context. That done, greater equality of incomes could well turn out to be a statistical mirage. Second, studies of inequality have concentrated on the individual, not on the kinship group. Yet, clearly, although the individual may be the earner, the family is likely to be the spender. Thus, although the husband, wife and dependent children may be assessed separately for tax (so long as there is no compulsory aggregation of household incomes), they are likely to spend at least in part as a collective. Statistics are misleading since, despite the appearance on paper of a movement towards greater equality of pre-tax incomes, yet the family might still have the same income base, albeit shared among a greater number of individuals. Such sharing of income might take the form of covenants transferring income to deprived earners who pay tax at a lower rate. Thus, for example, ‘a wealthy taxpayer with a separated wife, a mistress and four children (all with “separate” incomes under different schedules) might be represented in the Board’s yearly tables by six or seven income units’.7 Alternatively, sharing of income might take the form of the ‘one-man company’, created by a kinship group. Here one big salary (say, of an actor) is paid into the company, whose salaried directors are the earner’s wife and children (all claiming a personal allowance against tax). They vote to pay the earner a salary on a modest scale (while retaining the rest of his income as capital) and then ask him to spend their incomes for them along with his own. In this way progressive income tax at higher rates is avoided and statistical data are made impure via the transference of income from one family spender to another. Third, studies of inequality have tended to focus on income

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differentials, not on capital. Yet property (especially inherited property) can be a source of great inequality. A meaningful study ought therefore to take into account the time-dominated effects of accumulated rights and intergenerational claims. The existence of family trusts and stored-up wealth, influencing the command-over-resources-overtime to an extent that the spot distribution cannot capture, tend to benefit the unborn as well as the living. A meaningful investigation ought, clearly, to take into account a time-period much longer than simply the current fiscal year. Studies should be made not just of the distribution of property but of the way in which income can be and is being converted into wealth. A covenant can transform income into capital, as in the case where the beneficiary receives a lump sum at marriage or age 21. This lump sum will be tax-free since the beneficiary will already have been taxed on it (although not his older, richer father who would have been taxed at a higher rate). Moreover, an executive may accept a lower salary while working in exchange for a tax-free lump sum on retirement; or ask for a lump sum masquerading as compensation for loss of office. Where there is a redundancy, however fictitious or contrived, the payment is tax-exempt for the individual recipient (as well, of course, as being a deduction against tax for the company that pays). Such opportunities to convert pretax income into tax-free capital reduce the gradient of progressive taxation. They suggest that more attention should be paid to the concept of wealth and to the inheritance of status which it facilitates. Thus, in conclusion, it is natural to wonder if the tax system is really as great a burden on the rich as has often been supposed. Instruments such as covenants (which avoid both income tax and death duties) represent a substantial loss of revenue to the Exchequer and not all classes are in a position to benefit equally from them. Besides that, the rich are more likely to have the knowledge, the expertise and the opportunity to spread income evenly over time than are the lower classes. In that way as in so many others, Titmuss said, they are likely to have been well placed to frustrate the egalitarian objectives of progressive taxation. Such considerations lead inescapably to the question of whether inequality is today more of a problem or less of a problem than it was, say, before the Second World War. To this there is no clear answer. Titmuss says that remarkably little is in fact known about the changing distribution of income and wealth; that more study should be devoted to relative (quite apart from absolute) deprivation;8

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and that the ‘concealed multipliers of inequality’9 in economic and social institutions should not be allowed to hide where they fall. Concern with inequality, Titmuss stressed, is not passé.

Turning from the redistributive effects of costs to the redistributive effects of benefits, here again the key question must be: ‘Whose Welfare State?’ It is important to know who benefits from government expenditures on welfare. To many readers, the truth will come as a surprise: ‘The major beneficiaries of the high-cost sectors of social welfare are the middle and upper income classes. The poor make more use of certain services (for instance, public assistance) but these tend on a per capita basis to be the low-cost sectors.’10 In the case of the universities, for example, the ‘major beneficiaries’ are clearly not the children of recent immigrants or of manual labourers: Today 45 per cent of children from higher income and professional families are admitted to full-time degree courses at universities and their equivalent, compared with 10 per cent of those from homes where the father is in a clerical job, right down to 4 per cent where he is a skilled worker, and 2 per cent where he is a semi-skilled or unskilled worker . . . What is perhaps less well known is how remarkably persistent the inequalities in Britain have remained over the last ten to twenty years; the years of ‘The Welfare State’ . . . In point of fact, the relative chances of getting to university for working-class and middle-class children have changed little over the last quarter of a century.11 Those who have benefited most appear to be those who would probably have benefited most in any case. This has great disadvantages. For one thing, rather than automatically accelerating the social mobility of the achievers and the meritocrats, such an educational system may actually provide reinforcement to birth by making the family-gifted head start seem even more the result of personal accomplishment and innate ability: ‘The weight of evidence shows that in most European countries it has been one of the most powerful forces of social conservatism, giving the appearance of legitimacy to social inequalities by treating “a social attribute as a natural attribute”.’12 It thus has the ideological function of validating the social status quo. Moreover, rather than narrowing pay differentials, the educational

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system is likely to widen them. After all, education may have social and intellectual rewards, but it also has value ‘as a straightforward commercial investment’: The return on higher education as a purely commercial investment for the individual is probably larger today in most Western countries than any other form of investment. If heavily financed by the State, and if proportionately more children from betteroff homes benefit, then the system will be redistributive in favour of the rich.13 It is true that the working-class school-leaver may be earning good money at a time when the university student is struggling to survive on a grant (a grant to which the school-leaver contributes, of course, through his taxes). Later in life, however, the graduate may be twenty times or more better off . . . . measured solely in terms of annual cash income, with less disabling disease, a longer expectation of life, a lower age of retirement, more inherited wealth, a proportionately greater and more assured pension, a tax free lump sum perhaps one hundred times larger, and in receipt of substantially more non-wage income and amenities in forms that escape income tax, being neither money nor convertible into money.14 Clearly, the Welfare State, via the existing university system, is not helping to reduce either class inequalities (which may indeed become sharper once birth and property are reinforced by cultural formation) or earnings differentials (which are likely to become larger due to the premium on specialisation and training). Rather, the university system is itself becoming a pillar of inequality, operating with the rationalisation that economic growth necessitates more division of labour and more specialised training: As industrial, scientific and technological development demand more people with higher education there will be, as in Britain, pressures to invest more scarce resources in such education at the expense of education for the masses, and also to concentrate secondary education on those who will go on to higher education. These pressures, we must recognize, are growing stronger in our societies.15

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Such pressures are dangerous since they are a threat to social cohesion: These processes, necessary as they are, tend on balance to generate disequalizing forces and, by demanding higher standards of education, training and acquired skills, they can make more difficult the task of integrating people with different cultural backgrounds and levels of motivation. While we may raise expectations in people’s minds about what the future may hold, technology simultaneously raises the barriers to entry. This process, now becoming known in the U.S.A. as ‘credentialism’, is believed to be partly responsible for the solidifying of a permanent underclass of deprived citizens, uneducated, unattached and alternating between apathetic resignation and frustrated violence.16 A second illustration of the proposition that ‘the major beneficiaries of the high-cost sectors of social welfare are the middle- and upper-income classes’ relates to the National Health Service. There class equality of access and availability has not meant class equality of de facto utilisation: We have learnt from fifteen years’ experience of the Health Service that the higher income groups know how to make better use of the Services; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery; have better maternity care, and are more likely to get psychiatric help and psychotherapy than low income groups – particularly the unskilled.17 As evidence that the well-to-do on balance have higher medical consultation rates than do manual labourers (especially agricultural labourers), note that eye tests and dental treatment are proportionately more in demand in prosperous residential and commercial areas;18 and also that even under the free National Health Service the higher social classes appear to have received proportionately more blood transfusions than the semi-skilled and the unskilled who constitute social classes IV and V.19 This latter is a surprising result as the incidence of mortality and morbidity is actually higher in the lower-income groups. It reflects the fact that the middle classes have received proportionately more open-heart surgery and other medical interventions necessitating a transfusion.

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Naturally, the well-to-do have as much of a right as anyone else to the free-on-demand, as-of-right universalist services of the Welfare State. The point is simply that their share in the benefits has been more than proportionate to their numbers in the population (although all beneficiaries, it is generally agreed, do receive the same standard of service once the service is actually being provided): ‘Middle-income groups make more and better use of all services; they are more articulate and more demanding. They have learnt better in all countries how to find their way around a complicated welfare world.’20 This is not a criticism. On the contrary, it is good that the middle classes know their rights and insist on proper treatment. It remains, however, a regrettable fact that the hard-to-reach and even the unskilled do not have the same acumen and awareness. The consequence is that they do not consume the expected quantities despite a de jure entitlement which relates to need and to nothing else. There is a third illustration of the benefits bias. This is the tendency for the higher-income groups to enjoy more employerprovided benefits than do the lower-income groups. These complementary welfare benefits (which Titmuss calls ‘occupational welfare’, to distinguish them from ‘fiscal welfare’ and ‘social welfare’) are provided by firms to employees on the basis of achieved status and employment record. Such fringe benefits may take the form of a company car, a flat at a token rental, a subsidised mortgage or season-ticket loan, business trips abroad with rooms in first-class hotels, golf lessons, visits with clients to expensive bars and restaurants. The firm may provide an occupational pension for a key executive and his wife: employers often offer a higher non-contributory pension in exchange for a lower current salary as, while the pension will ultimately be taxable, it will be less than final salary and probably taxed at a lower rate. The firm may contract into death benefits; child allowances; payment of school fees; medical insurance; a works clinic. The list is a long one. It is no surprise to learn that occupational welfare may well have the effect of doubling the standard of living of some at least of the recipients.21 In practice, occupational benefits have many of the same functions as the benefits associated with social welfare: A substantial part of all these multifarious benefits can be interpreted as the recognition of dependencies; the dependencies of old age, of sickness and incapacity, of childhood, widowhood

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and so forth. They are in effect, if not in administrative method, ‘social services’, duplicating and overlapping social and fiscal welfare benefits.22 Occupational benefits are, however, not without their disadvantages as compared with the socially provided alternative. Occupational welfare, unlike social welfare, is selectivist. It thus nourishes privilege (by favouring white-collar workers and the middle classes) and promotes inequality (by increasing the gap between those with occupational benefits and those without). Occupational welfare, being divisive rather than unifying, weakens social loyalties and attachment to the nation. Occupational welfare, moreover, has the function of consolidating the interests of employer and employee (most visibly perhaps in the case of share options at subsidised prices). It thus contributes not just to good human relations in industry but to the creation of powerful pressure groups and a new corporatism. Occupational welfare is ‘mostly contingent welfare; the undivided loyalty tranquillizer of the corporation; the basis of a new monolithic society’.23 In that sense occupational welfare reinforces the power of the corporation in society in the same way as the communion and the confessional reinforced the power of the medieval Church. Also, occupational pensions and other forms of occupational welfare may be forfeited through job change or job loss. Unlike social welfare, such ‘golden handcuffs’ are self-evidently an obstacle to mobility. Titmuss warned that ‘a gradual hardening in the economic arteries of the nation’ could in this way result: ‘These new laws of settlement may, in time, constitute impediments to change as formidable in their own way as the laws which Adam Smith indicted in 1776.’24 Perhaps the British white-collar worker already feels as trapped as the Mauritian labourer who has moved into a ‘camp’ of tied cottages on a sugar estate: In their efforts to attract labour, some of the estates have taken considerable trouble to make these camps as attractive as possible, with playing fields and meeting halls. Nevertheless, the unwillingness of workers to live on the estates is understandable because of the loss of freedom involved in being tied to one employer.25

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Occupational welfare is an unhealthy system of provision from the point of view of society as a whole. Yet it is, ironically enough, society as a whole that pays a non-trivial part of the cost. Because occupational benefits are allowable against tax paid by the firm, about one-half of the cost in Britain (assuming a rate of corporation tax of about 50 per cent) falls on the general body of taxpayers in the form of revenue foregone by the Exchequer. The burden is even greater if all or part of the package is cost-pushed on to the consumer of the final commodity through an enhancement in price (a haphazard and regressive technique for financing welfare projects). Of course, some occupational benefits are taxed once they are in the hands of the recipient; but then not all, and seldom at their true market value. Even if the recipient were to be charged the full cost of the benefit, moreover, he would in fact be paying tax only on income he might have spent, not on income he might have earned. Where, however, the benefit is given to him in lieu of a far higher gross salary, income tax (possibly at higher rates) is avoided, the gradient of progressive taxation reduced, and the general body of taxpayers denied the levelling that the consensus demands. Most occupational welfare, Titmuss believed, is a cloak for additional net remuneration paid to those who need it least. Occupational welfare needs to be seen in connection with fiscal and social welfare if the present-day welfare system (made up as it is of three redistributive sub-systems, each of which alters the pattern of claims on current and future resources) is to work in the national interest. Titmuss writes that the welfare system is not in all respects working in the national interest at the moment. Taking into account all three sub-systems of welfare (i.e. not neglecting fiscal and occupational welfare, the two ‘submerged parts of the “Iceberg of Social Policy”’26), it was clear to him that, ‘as at present organized, they are simultaneously enlarging and consolidating the area of social inequality’.27

Social welfare has made the trend towards inequality less marked than it would otherwise have been. Even so, many gaps still remain in the matrix of the welfare systems. The tax burden has been less progressive than is often supposed, and the social services have not in practice favoured all equally but have favoured the well-to-do proportionately more:

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Take, for example, the case of two fathers each with two children, one earning $60,000 a year, the other $1,500 a year. In combining the effect of direct social welfare expenditures for children and indirect fiscal welfare expenditures for children the result is that the rich father now gets thirteen times more from the State in recognition of the dependent needs of childhood.28 Such differential treatment of different groups is a shortcoming in British welfare that must be put right. The challenge, as was seen in Chapters 5 and 6, must be met by selective discrimination. If welfare is really to redistribute life chances, then it must itself become selective and strive ‘to discriminate positively with the minimum risk of stigma, in favour of those whose needs are greatest’.29 A society which wishes to use its social services as a means of ‘equalizing opportunities for people in unequal circumstances’30 must recognise that proportionately more resources must be diverted to the socially disadvantaged than to the more successful if true equality in the state of welfare is indeed to be established. There should, in other words, be a greater emphasis on ‘community responsibility’ and ‘social growth’, of which the following are quantifiable social indicators: When our societies are spending proportionately more on the educationally deprived than on the educationally normal; when the rehousing of the poor is proceeding at a greater rate than the rehousing of the middle classes; when proportionately more medical care is being devoted to the needs of the long-term chronically sick than to those of the average sick; when more social workers are moving into public programmes than into private child guidance clinics; when there are smaller differentials in incomes and assets between rich and poor, coloured and pink families.31 Greater equality, planned and realised, is highly desirable from the point of view of the community. For one thing, social growth is not antithetical to economic growth, but is probably a complement to it: ‘More equality in income and wealth, education, and the enjoyment of the decencies of social living might conceivably be a democratic precondition of faster economic growth.’32 Besides that, equality of access to classless services fosters a sense of social integration. Morale in wartime Britain, as is frequently emphasised

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in Titmuss’s work, was considerably improved by ‘an equitable sharingout of food, shelter and social services’:33 Self-control was easier when there was no awareness of injustice arising from the way in which the primary wants were met. The knowledge that large numbers of those who were privileged in the community were also carrying on with their work and facing the risks that ordinary people faced, the knowledge that such facilities as the evacuation and shelter schemes were available and were not limited to particular groups – here were important foundations of morale.34 Clearly ‘there is a problem (as there has always been) of priorities in the allocation of scarce resources in the social policy field’.35 Yet, precisely because the existence of scarcity imposes the constraint of choice, it is important that priorities be set by socially determined criteria and that conscious decision-making replace the accident of birth or fortune. Titmuss believed that the community ought to identify those whose state of dependency is the most acute and then skew the distribution of the community’s wealth towards the citizens whose needs are the most urgent: ‘To me, the “Welfare State” has no meaning unless it is positively and constructively concerned with redistributive justice and social participation.’36 Understandably, of course, if one person is to be given a larger share in command-over-resources by the State, another must accept a smaller part. If, for example, ‘we are to plan for the aged to have a larger share of the National Income then we are, in effect, planning for others to have less’.37 One group’s welfare could well be another group’s illfare. Fortunately, however, consensus and not conflict is now the norm: ‘It is now widely accepted that in all sectors of the economy there is a national need to diminish both the absolute fact and the psychological sense of social and economic discrimination.’38 The community recognises the need for greater equality of opportunity and for reduced social distance. The community welcomes the planned redistribution that is carried out on its behalf by the democratic State. Differentiation, distinction and selective discrimination are essential. This is not, however, in contradiction with the imperative of universalism of benefits which remains the sine qua non:

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In all the main spheres of need, some structure of universalism is an essential pre-requisite to selective positive discrimination; it provides a general system of values and a sense of community; socially approved agencies for clients, patients and consumers, and also for the recruitment, training and deployment of staff at all levels; it sees welfare, not as a burden, but as complementary and as an instrument of change.39 Universalism is a necessary precondition for any policy of planned redistribution. Simply, it is not by itself sufficient to remove formal barriers of economic and social discrimination and to combat the heritage of neglect. The problem today is thus how best to differentiate without stigma within the framework of a universalist welfare structure. The aim must be to find ways and means ‘of positive discrimination without the infliction, actual or imagined, of a sense of personal failure and individual fault’.40 Today, positive selective discrimination must take place without those benefited being given any sense of secondclass citizenship, without any hurt being caused. The question is not whether the nation ought to redistribute social rights, but of how to do so without stigma. Some will object that this is impossible: ‘How in some respects can we treat equals unequally and in other respects unequals equally?’41 Titmuss, however, considered redistribution without stigma to be both possible and desirable. The techniques which he endorsed relate both to costs and to benefits.

Proposing reforms through costs, Titmuss suggested graduated and progressive national insurance and health service contributions42 in place of Beveridge-type flat-rate contributions which he dismissed as nothing less than ‘regressive poll-taxes’.43 In general, ‘there is a case for more redistribution through taxing the middle and uppermiddle classes more heavily by making them pay higher contributions for, e.g. medical care and higher education’.44 A flat rate means that the poor pay a higher percentage of their income than the rich in contributions. A progressive rate would eliminate that abuse and relate the burden more finely to individual circumstances.45 At the same time, across-the-board tax allowances regardless of need should be suppressed: ‘Reduction of tax allowances for children and old people is by far the simplest, most equitable and

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least costly administrative device for preventing “excessive benefits being paid to those who do not really need them”.’46 Because of the progressive nature of the income tax system, such allowances represent a greater subsidy to the rich than to the poor. Child allowances in the limit represent an indirect state contribution to the private sector of education and to the ‘old-boy network’ that makes childhood advantage into a lifetime capital asset. Titmuss believed that in future a greater percentage of the costs of welfare services should be met out of general taxation. This builds in a progressive bias and also means that revenue will come from taxes levied on unearned as well as earned income.47 Moreover, and this is largely implicit, he believed too that there should be a general re-examination of the nature of the tax system. Consideration ought to be given to the tax unit (the spender or the earner?), the tax base (income or wealth?), the balance of taxation (as between taxes on income, on outlay, and on capital), and to the problems of avoidance, evasion and alienation. Tax loopholes ought to be plugged; and Schedule A (the tax on the imputed rent that owner-occupiers pay themselves) ought therefore to be reimposed. Its disappearance has been a valuable subsidy to home-owners.48

Benefits, like costs, should be more finely tuned; but always, in Titmuss’s view, with due respect for impersonal classification. Selective discrimination must mean discrimination between groups as to needs but not between individuals as to incomes: ‘There is a case for more selective services and benefits provided, as social rights, on the basis of the needs of certain categories, groups and territorial areas (e.g. Plowden’s “educational priority areas”) and not on the basis of individual means.’49 The aim is, in short, for ‘positive discriminatory services to be provided as rights for categories of people and for classes of need in terms of priority social areas and other impersonal classifications’.50 Such discrimination on a territorial or group basis does not create ‘separate, apartheid-like structures’51 for the dependent, and those who are able to pay are not cut off or excluded. The state services are not left with a purely residual function since, even where resources are concentrated on those groups particularly at risk, there should in no case be formal discriminatory barriers that separate the socially superior from the socially inferior. In all cases benefits must remain citizen-based and as-of-right.

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That said, benefits within universalism may have to be tailored so as to appeal most of all to the targeted groups in the population. Thus, for example, ‘special educational policies directed towards equalizing opportunities for higher education’52 may be necessary if the children of the underprivileged are to represent a significantly greater percentage of university students. A university could discriminate selectively by admitting (particularly to vocationally oriented courses) older students who do not possess minimum entrance qualifications but compensate for lack of examination performance in secondary school by greater strength of motivation. As well as opening alternative doors, a university could open a greater variety of doors: it could almost certainly attract more workingclass children by offering more ‘specialized, vocational career courses’,53 courses which are likely to be more attractive than the humanities to children from poorer homes. Indeed, university admissions policies might even have deliberately to be geared to the general objectives of social planning: We may need to develop systems of quotas designed to widen higher educational opportunities; quotas for departments, for faculties and for courses, and quotas for different categories of students. Interestingly, it was only the intervention of the British government during the Second World War that led the medical schools to institute a quota of 10 per cent for the intake of women students to read for medical qualifications. This interference with academic freedom assuredly benefited society as well as women.54 Universities, in other words, must ‘respond to the welfare objectives of the wider society’,55 even to the extent of sacrificing some of their ‘academic freedom’. While each lecturer must remain free to teach as befits his own conscience, the same does not apply to the institution: ‘In institutional terms . . . there are and must be limits to freedom.’56 This is particularly so as the university system, left to itself, does not automatically and optimally satisfy the needs of the community. It is not just at the university level that there should be reform of the educational system in the cause of planned redistribution of life chances. Titmuss argued that in Britain, as compared with the United States, education was deeply divided by birth and privilege. He showed that even in 1961 a very high percentage of bishops, high-court judges and bank directors (and, by implication, other

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élites) were educated in independent schools, especially Eton.57 From this he drew the following conclusion: ‘Until we, as a society, can rid ourselves of the dominating influences of the private sector of education we shall not have the will to embark on an immensely higher standard of provision for all those children whose education now finishes when it has hardly begun.’58 It would be true to say, however, that the abolition of the public schools is not a topic to which he often returned. Alongside education, social security is another area in which the principle of selective discrimination can be applied with success. Labour’s National Superannuation Bill of 1970 provides a useful illustration of a proposal intended both to redistribute income from the rich to the poor and to concentrate help on those whose need was the greatest. The Bill proposed blanketing-in within a 20-year period: That is to say, instead of having to wait for forty-seven years (for male new entrants at age 18) – the period for which people would have had to contribute in strict actuarial terms – full ‘dynamised’ pensions would be paid within twenty years. This meant that all those currently over the age of 40 would be heavily subsidised – a redistributive effect particularly favouring married women re-entering the labour market and older immigrants from Commonwealth countries.59 The young paid for the old, the white for the coloured, and the sacrifice was compulsory. Welcoming the blanketing-in, Titmuss also welcomed the generosity. The pensions were not to be minimum or subsistence but adequate, pitched so as to guarantee a reasonable standard of living to old people not in possession of occupational benefits or significant savings without their having to undergo the indignity of applying for means-tested supplementary benefits. The definition of subsistence, moreover, was to be dynamised, continually redefined in relation to rising standards of living in the wider society to which the retired still belong. Here again the emphasis is on the overthrow of the actuarial principle of equity, that each individual should and can pay only the costs of his own pension. The scheme ‘thus presumed a willingness by society to accept an enlarged role for collective altruism in the future’.60 Labour’s 1970 Bill had the further advantage that contributions

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were to be earnings-related, not payable at a flat rate. This meant that additional revenue for the scheme could be raised without putting an excessive burden on the low-paid. It also meant that manual labourers were able to increase their contributions early in life when their lifetime earnings were at their peak. (White-collar earnings are subject to a peak just before the retirement age.) Again, benefits as well as contributions were to be wage-related, but here only up to a stated maximum. This would ensure a narrowing of the gap in old age between rich and poor: ‘Adequacy was defined in terms of a guaranteed income in retirement for an average earner and his wife of between 50 to 65 per cent of their combined preretirement life earnings. Because of the effects of the redistributive formula built into the scheme, the low wage-earner would receive a higher proportion.’61 Titmuss made similar proposals himself in recommending to the Government of Mauritius a skewed system of wage-related superannuation benefits in which the relationship between contributions and benefits was not to be the same for all levels of (past) income: The scheme should be designed to aid the lower-paid worker more than the higher paid. We recommend, therefore, that the lower-paid workers should be treated more generously than other contributors and should receive rather more than they would be entitled to on a strict actuarial basis. Taking account of need in this way is one of the major distinguishing differences between social and private insurance.62 The 1970 Bill, finally, was attractive to Titmuss because it provided for redistribution in favour of a number of classes of women. The policy of blanketing-in meant that women would not lose pension rights through late entry into the labour force (nor through absence from work due to child-bearing and child-rearing, sickness, unemployment, or periods of retraining). Moreover, not only were dynamised benefits to be credited to women in virtue of interruptions in their own careers, but they were also to acquire firmer rights over their husbands’ payments: ‘For example, a woman divorced before the age of 60 will have a legal right to take over her ex-husband’s dynamised contribution and credits record for the period both before as well as during the marriage. Widows aged 50 or over will have the right to inherit the husband’s full personal rate of earnings-related pension.’63 Thus the new scheme was ‘a new

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charter for women, whatever their civil status. Social security, especially in its longer-term aspects, is predominantly a problem of women and the prevention of poverty among women’.64 Titmuss also believed, however, that unnecessary positive discrimination should be rooted out, and that this was the case with the conventional practice whereby women, who have a longer life-expectancy than men, none the less retire younger. Clearly, ‘there is no justification here for a lower pensionable age for women’.65 Education and pensions are eminently suitable terrain for selective discrimination. So is insurance against disease and mishap. Titmuss advised the Mauritians to introduce a system of national insurance with wage-related contributions and flat-rate benefits. The latter were to be at a rate of 30 rupees per month. There was, however, to be an important exception based on demonstrated and certified medical need: The standard rate of benefit which we recommend is as close to the general level of wages as seems safe. There are, however, certain cases of sickness – for example, tuberculosis and deficiency diseases – where a high level of nutrition is essential to recovery. When such cases are diagnosed by medical officers we would like to see a higher level of benefit paid (Rs. 45 a month). This higher level of benefit would depend upon the specific recommendation of a Government medical officer and would be subject to review by the insurance medical officer. In such cases, considerations of the incentive to work are much less relevant and are anyway secondary to the need to restore working capacity.66 Medical need is consensually an important justification for positive discrimination in favour of a group. Thus in Mauritius, where anaemia, malnutrition and undernourishment are all common among young children, Titmuss felt that free milk should be provided for all pre-school children. Where possible there should also be a nourishing school meal for older ones.67 As with milk and meals, so with blood for transfusion, available to haemophiliacs in Britain regardless of ability to pay. In summary, then, it can be seen that there are a number of ways in which a society can skew the distribution of benefits towards those in greatest need; and in that way discriminate selectively within what must remain a basically universalist welfare structure. A society must not lose sight of ‘the connections between, for

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instance, bad housing and inability to profit from education’,68 and must remember that its attack on dependency must be made on several fronts at once. We are deluding ourselves, Titmuss writes, ‘if we think that we can equalize the social distribution of life chances by expanding educational opportunities while millions of children live in slums without baths, decent lavatories, leisure facilities, room to explore and space to dream’.69 And we need to think big. Titmuss believed that there should be redistribution between nations as well as within nations. He looked beyond the Welfare State to a Welfare World. Such a world, he was pleased to report, is well on the way to becoming a reality. After all, ‘inequalities between nations are now being considered in much the same way as inequalities within nations and between social groups’.70 Here once again, what is is rapidly becoming what ought to be. The process, however, is not automatic. Titmuss therefore distanced himself from the models of Radcliffe-Brown (who sought to prove ‘that the organic nature of society is a fact’)71 and Talcott Parsons (who attempted to sustain an ‘equilibrium-order concept’,72 mechanistic, conservative and self-stabilising). In such models integration and adaptation result spontaneously, with the implication that government intervention in the process of social equilibration is both unnecessary and undesirable. In Titmuss’s model, on the other hand, the self-stabilising order need not be the optimal order. Universalist public provision in the field of welfare is likely to be necessary to combat stigma, ensure the provision of social benefits to cover social costs, promote integration and involvement, and create an infrastructure that allows for planned redistribution of life chances and for differentiation without stigma. The counterpart of the models of Radcliffe-Brown and Talcott Parsons in the economic sphere is the ‘metaphysical individualism of the nineteenth century’73 that was championed by the Victorian economists who strove ‘to establish a competitive, self-regulating total market economy’.74 Methodologically speaking, their atomism is unacceptable. The ‘abstractions of economic thought’ do not situate the individual in the group and hence ignore the existence of social needs altogether. Besides that, their optimism is unwarranted. The market mechanism not only represents an amoral and an asocial instrument, but an instrument which in the social welfare field is strikingly inefficient. The fact is that state provision of universalist welfare services is preferable to the private-sector equivalent on narrowly economic

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grounds alone. Thus, even if allocation of welfare by the market mechanism were not unacceptable for social reasons, state intervention would still be preferable in order to attain the very goals to which the liberal economist himself assigns his pride of place. The last battle in the war against laissez-faire is evidently to be fought in the enemy’s own camp. The market has failed. The reasons for this failure as compared with the State may be examined under four headings: quality of provision, choice, quantity and price. These economic criteria will be examined in detail in Part Four.

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10 Part Three: Evaluations and Extensions

The end is equal status irrespective of lifestyles or endowments: We are all ready to love ourselves. The discovery of equality might be defined as the discovery that we have indeed to love our neighbours as ourselves. This in turn means the recognition of the full personal uniqueness of our neighbours. Just as each individual knows himself to be unique, so he sees that his neighbour is also unique. Human equality is an equality in uniqueness.1 The means is social policy, institutional and redistributive: This model sees social welfare as a major integrated institution in society, providing universalist services outside the market on the principle of need. It is in part based on theories about the multiple effects of social change and the economic system, and in part on the principle of social equality. It is basically a model incorporating systems of redistribution in command-over-resourcesthrough-time.2 Because we love, therefore we provide. Because we provide, therefore we love. Universalism is at one and the same time the effect and the cause of the consensus that cares. The end is equal status irrespective of the differences that divide. Part Three is concerned with the institutional–redistributive vision of the universalist services as agencies of social approximation. The previous chapters – Social Costs and Social Benefits, Integration and Involvement, and Planned Redistribution – explored the ways in which Titmuss combined the concepts of compensation, 158

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equity, donation, identity, taxes, benefits, moral choices and ‘the biological need to help’ in order to arrive at an activist welfare policy that was far more than simply a safety net for paupers with nowhere else to turn. The present chapter, concerned with evaluations and extensions, seeks to provide a context within which to assess what universalism in the sense of Titmuss may reasonably be expected to do. It is divided into four sections headed, respectively, Externalities, Blood, Community and Legitimation. The present chapter suggests that Titmuss assigned more importance to social welfare than so small a part of the social whole is likely ever to deserve. Expressing some doubts as to the means, the chapter is, however, very much in sympathy with the equal respect and the equal acceptance that is the end. Titmuss writes: ‘When men have this feeling for equality it expresses itself principally as an awareness of the worth of their neighbour and of the need to cherish him for himself.’3 No decent person would want to take issue with that.

(a) Externalities Some of the economic and social costs of development and change are borne by the individuals and businesses who themselves directly reap the benefits. The incidence of others, however, falls without private negotiation on third parties and non-participating bystanders. A opens a railway and B makes a trip – but C loses his forest as a consequence of the sparks. D opens a factory and E buys his goods – but, the river polluted, F as a result can neither fish nor swim. Arthur Cecil Pigou, in The Economics of Welfare, had pioneered the theory of neighbourhood effects, of the unintended spillovers of transition, of ‘uncompensated services and uncharged disservices’,4 using illustrations such as these. Pigou on economic externalities was a clear source of inspiration to Titmuss when he came to analyse the wide-ranging social diswelfares that a growthminded community imposes on a sub-set of its members in order that the set as a whole might thrive. Pigou’s forester and Pigou’s fisherman have a case in equity for damages to make good their loss. Titmuss, arguing by analogy, extends that same right not to be made another’s victim to the men and women who in times of product and process innovation become the price of economic growth. The costs of consensual choice must not be allowed to lie where they fall – and that means the State:

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Social Policy – Social Services – not all about beneficence (or more equality), also about partial compensation for the diswelfares of change (industrial injuries, war pensions, slum clearance, environmental disorders, the side effects of new drugs, the obsolescence of work skills, unemployment, etc.). Read Pigou (1924) ‘The Economics of Welfare’ – much neglected by the economists of late.5 Titmuss read Pigou but read him selectively. What Pigou was arguing was that the State should use taxes and subsidies to bring into alignment the net private and net social costs and benefits that would in the absence of intervention have led to an underprovision or an overprovision of non-contracted spillovers. Titmuss suppressed the option to steer by means of indirect taxation (a mode of microeconomic welfare in the sense of Chapter 4). He showed little interest in the restructuring of incentives that was the essence of Pigou on the managed market (the ex ante preventives and encouragements that, in Pigou’s theory, would induce the microunits to conform to the national will). Titmuss, in short, trimmed the Pigovian analysis of wild capitalism rendered serviceable by the State into a condition that was significantly less conflictual than the early Marshallians had envisaged. The community left rubbish behind. The State was invited in to clean up the mess. Society as the principal, polity as its agent – little could be more citizen-led than that. Titmuss simplified Pigou on the taming of capitalism into the harmonious organicism of a caring whole. Central to his welfarism is the axiom that social costs are imposed upon the social matrix by a social sum that somehow has a face. Quite different from his welfarism is, however, the perspective that many social costs are not imposed upon society by itself but on the majority by a minority, on the whole by a part. Where Jack and Jill have a picnic and the rest of us pay for the litter, there may be consensus as to the refuse collection but still not equity in the proposition that the State alone can pick up the pieces. Titmuss is attracted by the holistic vision of a seamlessly articulated collectivity. A less complacent, less accepting view would make society to no small extent a network of particularistic interests. In arguing that social costs should be paid for by the nation as a whole rather than by the specific individuals and firms who derive the associated benefit, Titmuss may well be doing the cause of Tawney-

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like welfare a certain disservice. Not only is he overdetermining his model by gilding compassion with compensation (in the sense that we not only love our neighbour as ourselves but also settle our debt to him in a time-lagged shopkeeper trade), he is also treating the welfare sector as the passive handmaiden of the interests of the market sector (a sector which Titmuss on balance mistrusts as an arena for selfish licence). In suggesting that social costs should become a burden on the State, Titmuss is underestimating both the power of science to isolate such guilty parties as there may be and the desirability of making the polluter pay for the damage that he causes on the road to his profit-maximum. Three examples will serve to demonstrate the contention that Titmuss was unintendedly cruel when he set out only to be kind.

Begin with the individual. It is perhaps salutary to distance sociology from the ideological knee-jerk that imputes to the improvident poor the ills that the hungry and the cold must ipso facto have brought upon themselves. Titmuss, however, goes to the opposite extreme and all but ignores the status of the discrete decision-maker either as the cause or as the cure. In the words of Alan Deacon: Titmuss’s determination to disavow individualist explanations of poverty led him to advocate a non-judgementalism which at times appeared to push him into a position of almost total determinism and towards a complete denial of personal responsibility. This in turn left the Titmuss Paradigm ill-equipped to resolve issues of obligations and incentives, and rendered it more vulnerable than it need have been to critics on the right.6 Titmuss, Deacon writes, did his best to replace the nineteenthcentury interpretation of deprivation as an indicator of personal failing with a new, more structural approach to intentions and consequences: ‘The problem of poverty was not one of individual character and its waywardness but one of economic and industrial organisation. As such it could not be relieved by measures which focused upon the character of those affected.’7 Titmuss’s social theory of causality was a salutary counterweight to capitalism’s factoring down. The shortcoming, Deacon would say, is not that it did what it did but that it did not know when to stop: ‘The Titmuss Paradigm is open to accusations of naivety regarding the pattern of

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individual rewards and sanctions which are necessary for wealth creation.’8 Titmuss envisaged a mixed economy, part welfare and part market. What he was reluctant to provide was a mixed theory of causes and cures that would be suitable for a society that had settled with him on the middle ground. Titmuss knew that a compromise was called for. Thus, criticising ‘the actuary and the economist’ for believing that the cost per case of road accidents ‘should lie (even to the extent of paying the “market price” for blood donations) with the individual or the insurance company’, he stated that the surrounding society favoured a more moderate position: ‘We have decided that some part of the costs . . . should be borne collectively.’9 Some part should be borne collectively – and some part should lie where it falls. Titmuss’s explicit recognition that human beings as moral agents must take some part of the responsibility for their choices and their actions looks forward to the some part position of Hoover and Plant on the middle ground: If the family is to be maintained and personal liberty secured . . . then it is wrong to reward as prodigiously as we do a narrow range of talent for which the individual does not bear full responsibility, and to make the costs of failure so heavy for those whose opportunities have been more modest, and who similarly do not bear full responsibility for their position.10 Hoover and Plant point with pride to the compromise nature of their democratic interventionism. Titmuss, on the other hand, makes clear that he is aware of the some part – and then effectively submerges it in Deacon’s ‘total determinism’, Deacon’s ‘complete denial’, in a manner that leaves his thought unnecessarily exposed to the charge of one-sidedness made by Deacon’s ‘critics on the right’. It was, interestingly enough, the right itself that had driven Titmuss to overstate his case. Titmuss was always concerned that the nineteenthcentury had passed on an inappropriate mindset to twentieth-century libertarianism: ‘The nineteenth century believed in original sin; it could not do otherwise while it worshipped so devoutly at the shrine of economic advancement.’11 Titmuss was struck by the fact that the great social upheavals of industrialisation, modernisation and urbanisation had been met, historically speaking, not by collectivist social thought but by the economist’s privatisation of unintended social outcomes: ‘Paradoxically, as the causes of dependency became

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more man-made (and less nature-made) they were increasingly judged in 19th century England to be solely the responsibility of the individual.’12 If Titmuss had not believed himself to be fighting a rearguard action against the twentieth-century successors of the nineteenthcentury individualists, he would probably have been critical of ‘socially derived sin’ (‘There are, we are told, no problem children, only problem parents’13) and not just of the ‘original sin’ which the economists had made the foundation for market capitalism. As it was, Titmuss wrote as if he were a man surrounded by enemies. The one-sidedness of his stance on social costs was the inevitable consequence of his self-imposed campaign to bend back the bent rod until it had become straight again. Inevitable perhaps; but still the exaggerated permissiveness does not do justice to Titmuss’s own high-minded vision of a harmonious whole in which each small unit has a role to play. Some illfare is not socially but individually generated – the result, say, of voluntary unemployment, excessive gambling, incessant smoking, non-stop drinking, promiscuous sexuality, recreational drug-taking, overindulgence in child-bearing. Privately engendered diswelfares resulting from causes such as these impose a double cost upon the whole. First, there is the de facto tax on living standards that is represented by a low propensity to save, to adapt to change, to be occupationally and geographically mobile. Second, there is the financial burden on welfare budgets that is the preventable consequence of parental abdication, reckless driving and an irresponsible attitude to rooftop safety. Clearly, not all social welfare is ‘compensation for disservice caused by society’;14 and much is in fact a weak-willed pass-through of private illfare donated to the community by bad Samaritans who expect others to pay. A theorist of duty as well as relief, one would have expected Titmuss to have been extremely critical of selfish citizens who impose a double cost upon their fellows. His reticence is out of keeping with the moral tone of his model. Possibly some costs ought to lie where they fall in order to affirm that even the responsible and the altruistic have a right not to be used. Social welfare, precisely because it separates decisions from their consequences, can potentially serve as an incentive for private individuals to economise on personal responsibility. Where welfare as of right weakens the practice of self-help and self-reliance, it can pass on to future generations the socially dysfunctional message that honour, honesty and assiduity are character-traits with which welfare’s children can safely dispense. Titmuss, importantly,

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reaches the opposite conclusion on the background moral assumptions: ‘I believe we can only build in these assumptions on the basis of comprehensive, universal services available as of right to everyone by virtue of citizenship. They are a fundamental prerequisite for the growth of a compassionate and civilised society based on self-respect and respect for the rights of others.’15 Social welfare does not create a situation where treatment gets in the way of eventual cure. Instead, it strengthens moral fibre and makes malingering ever less of a threat. Yet the threat is there. Titmuss states that it is ‘preferable both economically and socially that a man should work for a wage rather than subsist on a dole’;16 but he also underestimates the need to prevent abuse where the individual perversely prefers the dole to the wage. Ignoring abuse, of course, Titmuss is able also to ignore the police-state controls over the life of the dependent that are often required, in conditions of scarce resources, to weed out mendacity and guile. Such controls represent a man-made threat to civil liberties. They are disproportionately a diswelfare that must be shouldered by the poor. The poor, needless to say, are not the only beneficiaries of the Welfare State’s free gifts. The residualist favours safety-net assistance earmarked specifically for the absolutely deprived. The universalist, on the other hand, wants to open up the welfare experience to all members of the citizenship tribe. Desirable as such even-handedness may be in itself, one consequence is that a private surplus, a net increment in personal well-being, will often be generated in the process which simply cannot be regarded as social compensation paid for social diswelfares borne. State education is a case in point. Titmuss was aware of the private and personal differential that accrues in consequence of public investment in human capital.17 Concentrating on the spillover of skill, what he chose to ignore was the moral case for a universalism of access which also serves as an architect of inequality, a social overhead which promotes the affluence of the few through the contributions of the many. Of course the positive externality is a public good which feeds through into growth. Yet the skill of the accountant or the dentist is simultaneously a private good, an investment from which an appropriable return may be expected. The windfall element could be reclaimed through the withdrawal of subsidy for vocational education, student loans in place of student grants, the introduction of a graduate tax (levied, at the very least, on graduates who acquire a valuable capital

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at public expense and then seek their fortunes abroad). Titmuss, however, was a universalist; and universalism to him precluded a payment in exchange for a gift. The result is that it will be the marketing executive as well as the liar on the scrounge who will welcome welfare as an earning asset.

The firm like the individual takes home welfare from the State. Private business is entitled to a long list of complementary inputs from the nation as a whole. One of these is trained manpower: profit-seekers in the knowledge-intensive ‘new industrial State’ receive without user charge the lucrative gift of educated personnel and are not even expected to supply on-the-job apprenticeships in return. Another costless complement is roads. The car industry and the private motorist receive a subsidy in kind from the general taxpayer and do so in recognition of the fact that ‘we’ as a community prefer travelling by car to remaining at home. The appeal is to consensus; but the provision could none the less be made possible by tolls and road-fund levies instead of gifts. Prices would pass the cost of the service backwards to the producer or forwards to the consumer. Economics might admittedly mean a fall in cars purchased and road space demanded. Even if it did, however, that is not a reason to give support to one commodity when every other commodity must be said to be deserving of an equivalent respect. The same line of argumentation applies to health care. In the Titmuss model, the Welfare State treats the victims of road accidents free of user charge, as it does the sufferers from bronchial ailments brought on by air pollution, slum congestion or excessive smoking. Titmuss is tolerant of decorating without secured scaffolding and views fatty foods as a valid lifestyle choice. A more judgemental perspective would suggest the containment of redistribution from the health-conscious to the reckless by means of measures which proportion contributions to costs using a risk-related standard of selection. Car-owners could be required to pay supplementary National Health premiums because of the above-average demands they are likely to make. A hypothecated tax on cigarettes could be levied to cross-subsidise the additional burden on the medical services. In ways such as these the diswelfares of illness could be paid for by the producers and the consumers without the need for the nation as a whole to subscribe to the cost. Internalisation of the negatives protects social welfare from the

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need to pick up the litter that some people but not all people have calculatingly left behind. Minimum wages transfer from the taxpayer to the profit-seeker the responsibility for the low-paid. Visors and helmets reduce the incidence of work-related injuries. Leadfree petrol and the prohibition of carcinogens move firms on to a less noxious production function. Maternity leave and childcare at work mean that the business and not the State takes over the liability. Employers will gnash their teeth at laws and regulations which cut into their economic return. Both consumer protection and fringe benefits are, however, long-established features of commercial life. Their institutionalisation as a functional and an equitable alternative to social welfare should not be written off prematurely. It would be a mistake to infer too soon that social costs without social welfare are bound to lie where they fall. Titmuss’s insistence that the community and not enterprise must provide services in acknowledgement of the externality is in that sense a blind-spot in his economic sociology. Critical as one might be of his passivity and even of his defeatism, the assessment cannot be challenged that he was stoical and accepting. Here is Titmuss, in an unpublished lecture in 1954, calling it a duty of the social services ‘to receive and support the casualties of the economic system: – the compulsorily retired, the rejected, the industrially injured and sick, the victims of road accidents (10% of hospital beds)’.18 Here is Titmuss, in his last major paper in 1972, stating that externalities are the ugly face of prosperity: Industrial systems in the more affluent societies do not include in the cost of what they produce such diswelfares and diseconomies of production and distribution as the spewing out of effluents into the air, the over-loading of the land with solid waste, water and food pollution, industrial and transport hazards or the lack of any charge for the eventual disposal of used-up goods. Thus, they pass on a hidden and heavy cost to the community in the destruction of amenity.19 They do and we must pay: that is why society must provide hostel beds for coal-miners whose health has been broken by pneumoconiosis and must treat in public hospitals the victims of other people’s pesticides and weed-killers. They do not if we refuse – if society and its lawmakers inform the business community that there is more to the social economy than financial gain alone, and that

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preventive and corrective action cannot automatically be hived off to some convenient Welfare State of first resort. Titmuss was stoical and accepting. His accommodation with business is an integral part of his socialism as social services. Advocates of microeconomic welfare will suggest that his interventionism requires an additional front.

A third and final example of the handmaiden function is the phenomenon of social solidarity. Titmuss writes that ‘the welfare state has evolved as a particular manifestation of Western democratic societies’.20 He also states that social welfare has been ‘a major force in denying the prediction that capitalism would collapse into anarchy’.21 A cynic would see in these two propositions a simple papering over of the cracks, an inference that welfare professionals in effect practice tension management by empowering the vulnerable to survive in the self-seeking market. A cynic would argue further that if it is indeed society that produces the dependent, then society should cease its unjustifiable attrition rather than attempt to resocialise its victims within the framework of an intolerable status quo. A cynic might even suggest that individual therapy can actually impede needed social change where it represses genuine economic contradictions that without the manipulation of consensus would have shunted the democracy on to a different line. An instance of this unexpected latent function is to be found in the case of crime. Titmuss argues that for dead-end school-leavers who lead deprived lives in a spirit-crushing urban slum, rule-breaking is ‘the one remaining major form of acquisitive social mobility’.22 He shows remarkable tolerance towards society’s outcasts, refusing to hold them fully accountable for the character that history has stamped on them in the course of economic upheavals lasting four generations or more: ‘The social ineffectives of yesterday cannot be treated differently from the social ineffectives of to-day . . . The sins of yesterday become greater sins; they reach out further into the future; they grow as our understanding of human need grows.’23 Time passes on the costs. Deviance is one of the costs that the affluent society inherits from Crompton and Arkwright. Crime, Titmuss says, is ‘a social ill or a “social problem”’.24 He expresses the view – without, however, committing himself to compensation paid to the criminal for bearing the costs of other people’s progress – that the devil in the piece has ‘more of the character of Bentham than of Freud’.25 He comes down in favour of selective

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discrimination as a means of reclaiming the most marginalised for what is basically a going concern. Yet it is just here that the difficulties begin. If the thief is merely the fashion-victim of conspicuous consumption and the wife-beater the product of adultery and divorce, can no rule-breaker be expected to exercise self-control? Might not healthy as well as dysfunctional deviance be discouraged by social policy for the very reason that even a reformer like Titmuss himself must initially appear a deviant until the central value-system has fully absorbed his ideas? Should society have no unique valueconsensus, whose values then should be inculcated in the estranged? Titmuss in any case associates rule-breaking with inequality and exclusion. The market, on the other hand, values success above ethics. Should crime be an emanation not of social distance but of a normative vacuum, there is not a great deal the social worker can do except to ring for the police. Another instance of the way in which Titmuss believed the Welfare State could resolve social tensions brings in the corrosive of unfulfilling labour. Titmuss complains of ‘the degradation of the worker’ in a system of scientific management and advanced technology where ‘the machine tends to regulate and control the work’.26 He reflects on the contradiction that the manual labourer is expected to be passive at work (the tool of others) but active at home (the master of his destiny and of that of his family). Such an unbalanced state of affairs leads him to the following conclusion: ‘In so far, then, as modern industrial techniques lead to feelings of personal dissatisfaction, to a dispossession of personality, the problem thus becomes a family and community problem.’27 What is striking here is that the cure has little or nothing to do with the disease. Titmuss is simply arguing that the pressures of economic growth and industrialisation generate personality problems too great to be dealt with by the family alone (despite the central role that it plays in all societies) and that this imperative necessitates social involvement: ‘It is in this context that we need to see the social services in a variety of stabilizing, preventive, and protective roles. Interpreted in this way, and not as the modern equivalent of Bismarckian benevolence, the social services become an ally – not an enemy – of industrial and technological progress.’28 The social services, in other words, are expected to deal with pathological cases, and to deal with them in accordance with society’s needs and values. Yet Titmuss has little to say about the roots of pathology, and tends to regard as outside his remit the forces in

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the market sector that cause men and women to flee across the border into the Welfare State. He assigns little blame to onedimensional and uncreative work; to powerlessness rather than participation; to class conflict and the resentment of rentier couponclippers. Titmuss is reluctant to attribute to the market sector the responsibility for the material and psychological diswelfares that must ultimately become a charge upon the State. He also confuses the issue of origins by using ‘alienation’ in the sense of anomie, in the sense of perceived normlessness that can be overcome by closer ties within a more integrated community. It may be the case that both alienation and anomie have deep roots in economy and society; and that, if so, a National Health Service can only relieve the present symptoms without striking directly at the underlying cause. In such a situation a socialist economy might result, were it not that yet another unexpected function of the Welfare State appears to be a truce on public ownership. In Sweden, as Gunnar Myrdal has explained, the result of four decades of Social Democratic rule ‘has been large-scale social reforms, but practically no nationalisation of industry, commerce or finance . . . Sweden now stands as the one country among the developed nations where business is almost entirely left in private hands, even more so than in the United States with its absolutist faith in private enterprise.’29 Association is no proof of causation. Were it true, however, that social welfare, concealing the ugly face of market capitalism, also discourages the nationalisation of the economic base, then the externality would lend some support to the view of those socialists who argue that the social services are a reflection not of integration but of malintegration, not of harmony but of division. Such socialists explain the origins of welfare with reference to the needs of the economic system as perceived by a ruling class. They suggest that the Titmuss model is an exercise in value-manipulation which, never intending to frustrate the socialisation of assets, preaches a fiction of social integration which is seriously out of touch with the material circumstances of the times. Partly because Britain had so extensively nationalised her industrial base, partly because class exploitation was never to him the overriding cause of discord, Titmuss would not have accepted that there was a negative correlation between social welfare and socialist economics. What he would have accepted is that the have-nots, even if not the gravediggers of the bourgeoisie, can still represent a threat to social tranquillity where they riot in Harlem and loot in

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Watts: ‘In the long-run I believe that a more socially harmonious and equal society could be a more productive society. In any event, it will not have to bear the immense economic costs of race riots and race wars such as the United States has experienced.’30 Indeed it has; and one of the strongest opponents of that ‘private opulence and public squalor’31 which drives the poorest of the poor to desperate action has consistently been Titmuss’s contemporary, Galbraith. Writing in support of greater public spending at the time when the American blacks were becoming increasingly vocal about poverty and social distance, Galbraith invited the haves to reflect on how much they stood to lose: ‘Perhaps the disadvantaged are now too few to make a revolution. But they could make life uncomfortable for all.’32 Whether a handout or a hand up, social benefits in such circumstances are not so much compensation paid to the deprived for the externalities they have supported as a preventive first strike intended to stop the deprived from inflicting externalities on the rest of us. A stock-broker who wants to drive safely to the opera would evidently be well advised to vote with Titmuss and Galbraith for a generous Welfare State.

Citing the three examples of the individual, the firm and the social matrix as a whole, this section has argued that there is much to be gained from a narrowing and a deepening of Titmuss’s theories of social costs and social benefits. One of the principal extensions would have to be an unambiguous distinction between social causality and social obligation. It is tautologous to say that social phenomena are social facts in the sense that they are observed in a social context. Thus higher fertility-rates and earlier marriages (both reflected in the part because they are patterned in the whole) will normally mean a shortage of housing and of schools (thereby occasioning a social cost); while the social overhead of education, reducing illiteracy and diffusing skills, is likely to confer a social benefit in the form of higher productivity and faster growth. Better living standards, through improving the average health of the nation, mean in turn a greying population that, increasingly elderly, is increasingly likely to be a burden on scarce healthcare services. Indeed, the demand for medical attention itself is social as well as physiological in origin, an expression in time and space of ‘particular forms of society and cultural patterns’:33

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‘The more that a society as a whole values success in life and fears death the higher may be its demand for medical care in some form or other.’34 Even the sensation of pain or stress is refracted through the perception of pain or stress, in no small measure a common standard of the normal and the pathological. Nowadays, ‘more people have grasped the idea that pain can be avoided’,35 and there is also ‘a heightened awareness of what medicine has to offer’.36 Attitudes to health, disease and the doctor are most definitely social facts. Social causality does not, however, imply social responsibility, and to reason as if it does is functionalism run wild. Because each unit in the social basket is aggregated with all units in the social basket, it does not follow that each part is responsible for all parts. Such functionalism masks microsociological lines of causation and conceals the specific allocation of costs and benefits. In some cases, of course, social diswelfares do necessitate social services. The justification may be considered both in terms of prevention and at the stage of restitution. The model for prevention is the containment of disease. Here the argument for third-party provision is precisely the fact that a third party is involved – not just the consumer (the patient) and the supplier (the doctor) but the catchment community as a whole. Titmuss takes his own example from the experience of Britain at war – from orderly evacuation (a desirable alternative to panic flight); from homelessness and injury caused by enemy bombs (where in the absence of redress workers would not have remained in the cities); from nurseries provided for the under-fives (since such facilities both released mothers for factory work and bolstered the morale of fathers at the front); from neuroses brought on by air raids (since such conditions, if left untreated, would have been a visible crack in the nation’s resolve). War is a contagion which affects every member of the community. It is also a politicising phenomenon. The government in wartime is generally accepted as the agency which mobilises the citizens in the service of a common cause. The model for restitution is compensation paid for clothing soiled, damages awarded because amenity has been reduced. The restoration of the earlier utility level that obtained before the non-ego shock is the action clause in Pigou’s welfare economics, as it is in Titmuss’s non-quantitative reinterpretation of the microeconomics of interdependence. Any justification that relies on consensus (the

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point was previously made in Chapter 4) must always be the hostage of vague impressions and debatable guesses. That said, S.M. Miller, much influenced by Titmuss on punishment without crime and the victimisation of the vulnerable, illustrates the ‘devil-takethe-hindmost’ scenario where ‘many suffer for the benefit of others’ with the not unconvincing example of ‘unemployment as an antiinflationary device’: In order to curb inflation and thus benefit exporters in particular, many suffer a severe drop in income. This decline is not due to anything that the unemployed have done. They are bearing the burden for the rest of society of an anti-inflation programme. To placate the anti-inflationary gods they are sacrificed on the altar of the Phillips Curve so that ‘all’ of the economy could presumably benefit. A disservice has been done to the sacrificed which should be atoned by unemployment benefits without stigma.37 The unemployed, the ‘sacrificed’, are bearing the costs of their nation’s macroeconomic stability. It would be more equitable, Miller argues, for the whole that enjoys the gains to look after the expendable who have lost their livelihood in the service of their nation. Both in terms of prevention and at the stage of restitution, it would be difficult to deny that social diswelfares in certain circumstances do indeed point to social services. What cannot be accepted is that social externalities must in all circumstances be the trigger for social support. Large families impose a burden on schools – does this mean that the community as a stakeholder has an ex officio obligation to pay? Old people run out of money – was it low pay or lack of foresight that accounts for their present-day distress? A baby is battered – should the baby or the batterers be offered compensation for the stresses of modern life? A line must be drawn somewhere if individual fault and private responsibility are not to disappear entirely. Fully aware that there was such a line, Titmuss never drew it or said how it should be drawn. Relief of distress, he believed, was inevitable irrespective of the cause. Lines stigmatise, mistakes can be made, and fine distinctions serve no useful purpose. We start from here. Causality is forever bygone when the drunk lies bleeding on the floor.

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As will by now have become apparent, Titmuss’s conceptualisation of the handmaiden function is beset with a fundamental contradiction. On the one hand social welfare is defined as a system of unilateral transfers, of free gifts to strangers. On the other hand, however, social welfare is treated as a mode of reimbursement – and in this latter case it is reciprocation and not compassion that governs the release of resources. Society is deemed to owe the dependent a gift in exchange for the gifts they have already made to the collectivity (even though the initial gift was unintended, not planned, compulsory, not voluntary; and despite the fact that there is no way of measuring gift-equivalence with exactitude). Such transfers are not unilateral but a quid pro quo. They are not n-person altruism but the settlement of a debt. A dependent person denied welfare on the grounds of ascription can immediately resubmit the identical claim on the grounds of contract. The dependent evidently have quasi-commercial rights which entitle them to benefits from the collectivity. The collectivity, curiously, appears not to hold an analogous set of rights which would allow it to expect a certain minimum of self-care from the dependent. They have rights. We have duties. The relationship is an unequal one. T.H. Marshall shared with Titmuss the conviction that the nation cannot back away from its destiny: ‘The claim of the individual to welfare is sacred and irrefutable and partakes of the character of a natural right.’38 Where they differed is that Titmuss refused to explore the possibility that rights come with duties attached whereas Marshall positively gloried in the extent to which a gift is, as in Malinowski’s Kula, but a single unit in a patterned skein. In acquiring an entitlement, Marshall said, citizens also acquire a commitment to return the gift. Even free-on-demand healthcare carries with it the expectation that the consumer will exercise regularly and not smoke to excess: ‘Your body is part of the national capital, and must be looked after, and sickness causes a loss of national income, in addition to being liable to spread.’39 T.H. Marshall believed that the right to use other people’s resources was bound up with the duty to play one’s part: ‘It would be dishonest to pretend that there is not about welfare policy decisions something intrinsically authoritarian or . . . paternalistic.’40 Titmuss was never at home with the exchange paradigm, implicit or explicit, social or economic: ‘People, we should remember, do not “play” roles like actors. A role is something that a person is.’41 The benefit is the decency. The cost is a theory of externalities

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which throws out the baby with the bathwater by shying away from the causes of pathology – and by dispensing absolution when what is required is guilt.

(b) Blood The Gift Relationship was published in 1970. It was Titmuss’s last book and his most influential. In his synthesis of empirical social survey with the ethics of service and care, as Oakley and Ashton write, he came closest to outlining an integrative theory for all his work in the field of social policy. The book is the clearest statement of his moral philosophy: the view that a competitive, materialistic, acquisitive society based on hierarchies of power and privilege ignores at its peril the life-giving impulse towards altruism which is needed for welfare in the most fundamental sense. The Gift Relationship exemplifies well that formula of political arithmetic and ethical socialism which Titmuss inherited from British social science and made peculiarly his own.42 Few other contributions to economic sociology are as creative or as inspiring. The book took seven years to write. The background was prosperity and consensus, ‘Swinging London’ and Harold Wilson. It was also the pro-market Institute of Economic Affairs. Titmuss’s paper on ‘Ethics and Economics of Medical Care’ (the episode is discussed further in Chapter 15) could have led to a libel action in 1963. In 1966 his Fabian Lecture on ‘Choice and “The Welfare State”’ – the lecture in which he first stated that blood donation was economically efficient – provoked Arthur Seldon at the Institute to call the view ‘a romanticised idyll’.43 In 1968 Michael Cooper and Anthony Culyer published their Hobart Paper No. 41 on The Price of Blood which Titmuss in The Gift Relationship castigated as a step backwards into greed: the Institute and the economists, he wrote, ‘wish to set people free from the conscience of obligation’.44 In 1973 (the same year as the Pelican republication of Titmuss’s book) the Institute made its reply through a collection of essays entitled The Economics of Charity – a collection in which The Gift Relationship was effectively dismissed as an exercise in ‘pseudo-science’45 rather than an uplifting demonstration that good deontology can be good

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consequentialism as well. Begun at a time when Labour was just ending 13 years in Opposition, Titmuss’s study of blood must also be seen in the context of his dispute with the pro-market Institute and with the libertarians who were later to become the Thatcherite New Right. Blood as a symbol could not be more evocative. Blood is equality: all classes, all races have in common the circulation of blood. Blood is life: to give blood is to enable a fellow human being to survive. Blood is trust: people donating today are relying on future cohorts Burke-like to pick up the torch. Blood is socialism: people give without payment because they know that the National Health will not sell on for profit. Titmuss in choosing blood could not have chosen a more evocative symbol of welfare as humanity and community as family. Poetry and philosophy validate Titmuss’s choice of blood. Social science, however, is a different matter. This section suggests that Titmuss may have gone too far in pyramiding the social ethic on an unrepresentative base. Yet a sociologist is rightly to be judged by the sample he keeps. The blood donors at the very least are a sensitive indicator of how Titmuss himself saw the integrated community in his own actively welfarist times. The gift of one’s life-blood conjures up an image of sacrifice and finality. The impression is a misleading one in view of the speed with which blood alienated in the day renews itself automatically in the night. A more meaningful indicator of social involvement would therefore be a redistribution that does not effortlessly bounce back. One index of social involvement and ‘conscience without shame’46 would be money given to charities, at home and worldwide: ‘Pakistan appeal £1 million – suggests that public opinion sees the problem as One problem – if we care then we have to care simultaneously with both the World and the Parish.’47 Another proxy would be the gift of a kidney or of bone marrow. Other measures would be unpaid participation in community self-help schemes; voluntary staffing of adventure playgrounds and citizens’ advice bureaux; the willingness of workers to cover the duties of weaker colleagues who might otherwise be dismissed; the willingness of employers to take on released prisoners and rehabilitated derelicts because someone has to give them a foothold. Blood is one indicator among many. Arguably, it is not the most convincing. Indicators of social irresponsibility are, as it happens, no less easy to find. Families are abandoned. Litter is dropped. Electricity workers

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go on strike despite the high cost of hypothermia that is paid by the old. Bus fares are dodged even though, as Titmuss puts it, ‘people who defraud the Government defraud themselves’.48 Shops are lifted, taxes fiddled, coin-boxes vandalised. A sample of 3813 unemployed addicts with a high profile in insider trading would give a very different picture of egoism and altruism in modern Britain from that which emerges in the Titmuss study of 3813 blood donors prepared to accept some discomfort and give up some time in order to transfer an asset which the body will quickly restore. It is by no means easy to decide if we as a national family more closely resemble the City speculator who makes a killing in futures or the altruistic mother who donates her breastmilk to nurture another woman’s child.49 Titmuss makes the task that much more difficult through his concentration on the generous to the exclusion of the disaffected. The lack of a control group seriously undermines the philosophical generalisations that can be made on the basis of Titmuss’s sample survey. Even if the 3813 donors polled did in fact constitute a representative cross-section of the British blood donorship in 1967, they are unlikely to have constituted a good cross-section of the British population as a whole. Titmuss’s sample, selective as it is, reveals no more of the social attitudes of the vast majority who do not give blood than a fragment of Socrates’ toe-nail would reveal of Socrates. Should the blood donorship not share the median social values, it would be a serious methodological error to confound their pathological behaviour patterns with the normalcy of the central value-system, or to mistake their desire to help for a widespread social fact.

Assembling the evidence, Titmuss shows that Britain, of 27 countries in his study, was the only one not to offer financial incentives or other compensation. As is so often the case, however, he is reluctant to accompany the what with a testable why or to explain in detail the precise causality of the welfarist impulse. Titmuss argues that in Britain, using the indicator of voluntary blood donation, the gift relationship is a strong one. Both in America (the leading capitalist nation) and the Soviet Union (a planned economy relying heavily on command) it is weak. Clearly, the social force that fosters altruism and represses selfishness is not to be found in the economic basis: America is committed, materially and intellectually, to possessive individualism and market self-interest whereas

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the Soviet Union had nationalised the means of production, distribution and exchange that socialists have often seen as the source of social mistrust. Nor, however, can ‘the demand for one society’ 50 as measured out in blood be traced back to the welfare environment: both America and Russia share with Britain a commitment to free state schooling, while Russia too embedded its transfusions within the protective universalism of citizen-based healthcare. The crucial variable which promotes a sense of belonging remains, in short, unidentified and unspecified. Reluctant to specify the logic, Titmuss is quick all the same to spell out the consequences: ‘If the bonds of community giving are broken the result is not a state of value neutralism. The vacuum is likely to be filled by hostility and social conflict.’51 Blood donation reaffirms group attachment. Blood-selling threatens other-regarding conduct. Taken literally, as Cooper and Culyer observe, the claim makes little sense: ‘It is almost beyond belief that the introduction of payment (in some form) for blood supplies in Britain would provoke “hostility and social conflict”.’52 Interpreted liberally, as Titmuss would have wanted, the contention is more plausible. Free gifts like truth-telling and mutual support probably are the sine qua non for tolerable survival in a society that does not want to pay the transaction costs of security guards to help old people to cross the road or to live in constant fear of the dog-eat-dog bellum of which the failure to give up one’s seat to a pregnant woman can well be the thin end of the wedge. Blood may be an indicator; but still the altruistic impulse does not begin and end with blood alone. The gift of blood is a special topic in the general theory of habit formation and institutional evolution. That is why Titmuss’s account of transfusions must be extended and amplified if it is to explain the origin and adoption of the other-regarding conventions. In places he writes as if blood transfusion in symbiosis with the National Health is able to pull itself up by its own bootstraps: ‘The number of effective blood donors, freely and voluntarily providing “gifts” (as they are known) has risen by nearly 300 per cent since 1948 . . . [This] is no small tribute to the general approval by the public of the National Health Service.’53 In other places he makes much of man’s ‘biological need to help’54 in which as a lapsed eugenicist he will have recognised the Darwinian survival of the fittest group that Kropotkin (as did Alfred Marshall) uses as the foundation for his defence of ‘mutual support and mutual confidence’ among the bees, the pelicans, the termites and the ants: ‘Those

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animals which know best how to combine, have the greatest chances of survival and of further evolution.’55 Titmuss writes in places as if of bootstraps and in other places as if of Kropotkin. The ingredients for the cake are there. The general theory of the gift relationship is not.

Titmuss never says how much altruism a mixed economy actually needs or wants. Ranking morality of intent above utility of outcome, he does not believe it necessary to set a maximum to the generosity that is supplied or to prescribe the optimal areas towards which giving should most urgently be directed. More serious a problem is, however, his unwillingness to accept that altruism might not be enough for the task in hand – and that commerce in such circumstances might prove the cost-effective choice. Titmuss asserts that there is a shortage of blood in the United States but not in the United Kingdom. Cooper and Culyer reply with a sample survey of their own suggesting that as many as 42 per cent of British surgeons were obliged ‘sometimes’56 to postpone surgery because of a lack of blood. Payment for blood would have made possible the interventions put off. Even if the gift is ethically superior to the sale, the fact remains that inadequate supplies can mean a loss of life and that forgotten patients too have a moral value. Market economists see it as the great advantage of the invisible hand that microeconomic pricing brings into balance the quantity demanded and the quantity supplied. Blood for transfusion, corneas harvested from cadavers, kidneys transplanted from living donors, babies bred for eventual adoption – Titmuss would say that a sacred limit had been infringed where a thing is privatised and commodified which ‘touches the deepest feelings in man about life and death’57 whereas market economists would dismiss as a life-threatening superstition the belief that the partners to a trade should be denied the freedom to reap what in their own eyes would be an enhancement in well-being. As Hansmann says, writing of the sale of one kidney by a person who takes a greater risk when he works on a building site or rides home on his motorbike: ‘Any individual who would agree to sell would evidently rather have the money than have the slightly greater chance of avoiding the death or illness that would result from keeping the kidney.’58 Even Titmuss’s ‘blood proletariat’ is entitled to the right to choose.

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Titmuss, needless to say, did not have to bow before the logic of the ‘private vices, public virtues’ compromise to which Adam Smith was referring when he wrote: ‘It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest.’59 The reason is that Titmuss was confident (however debatable his assessment) that private virtues alone were fully capable of delivering sufficient blood: ‘In Britain . . . there is no shortage of blood.’60 Soon after 1973 the Americans went over to the British system of voluntary donation – and there at least there was a shortage, so great indeed as to lead Roberts and Wolkoff to recommend a return to buying and selling: ‘Approaches based on increasing the personal reward for giving are likely to increase supply and allow collectors to become more selective in the blood they use.’61 At some price even healthy young professionals will become responsive to the pecuniary incentive. At some price the regressive transfer in the sense of Titmuss will be crowded out by the finely calculated avarice of speculators who sell blood on the way to the bank.

Titmuss, rejecting blood-selling as unequal and exploitative, neglects the sense in which the freedom to alienate that which is unmistakably one’s own makes the have-nots more self-reliant precisely because it redistributes in their favour valuable compensation from the haves. Blood sales are a two-way flow. Nor should it be forgotten that the lower-income groups experience more illness and more accidents than do the managerial and professional classes. The lives that the ‘blood proletariat’ saves can be blue-collar lives and not merely the lives that winter on a yacht. Blood-sellers are not a good cross-section of the national pool. Blood donors, Titmuss asserts, are a different breed: ‘In terms of income and social class the blood donor population is broadly representative of the general “eligible” population.’62 His data suggest a different inference: ‘Social classes I, II and III are over-represented and IV and V under-represented.’63 The better-off seem to be giving more than the poor. The better-off, on the other hand, are also more likely to receive a transfusion. If blood donorship in Britain were indeed to be ‘broadly representative’, the rich would in effect be enjoying a net transfer from the poor. This is the very state of affairs that Titmuss found so repellent in the American case. Payment can take many forms. One of them is self-felicitation.

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A great number of the answers to Titmuss’s questionnaire pick up a profound desire to feel good about oneself, to feel that one has lived up to one’s ideals and not defaulted on a debt. The relationship is a conscience nexus. Titmuss chooses not to see the gift as an implicit exchange or to incorporate social pressures as a functional equivalent of the economist’s quid pro quo. Precisely because the gift is uncoerced, however, it stands to reason that the donor must feel that his satisfaction level would be higher in consequence of his altruism than it would have been without it. Even if people are not selfish, still they may be said to be own-gain-seeking. Middleclass donors in the Titmuss model are allowed to seek their own gain through gifts. It is asymmetrical that the ‘blood proletariat’ should not be allowed a similar freedom to act through commerce in pursuit of felt well-being, self-defined.

Titmuss says: ‘Private market systems . . . deprive men of their freedom to choose to give or not to give.’64 Logically speaking, the same must be true of the State when it interferes with the freedom to sell. A tolerant compromise, steering a middle course between the either/or and the all-or-nothing, would therefore be a mixed blood economy in which the humane donate and the mercenary sell, the one motive supplementing the other in such a way as to maximise the saving of lives. Titmuss, however, rejected the twopronged approach. Partly he did so on the grounds of fellowship: an ethically minded citizen does not charge for something which is special. Partly he did so on the grounds of degradation of product: duality would tempt altruists to sell, shame the self-denying into less tainted outlets, and release into the community the blood-borne plague of hepatitis. Kenneth Arrow, arguing against Titmuss for both of the options to be kept open, believed that Titmuss exaggerated the incompatibility of the alternatives: ‘I can find no support in the evidence for the existence of such a dilemma.’65 Peter Singer, arguing against Arrow that the admission of a market would undermine a pre-existent mutuality, concluded from Titmuss’s evidence that it was indeed likely that a crowding-out would occur: The overall picture . . . is that where payment for blood is unknown, the number of voluntary donors has risen and kept pace with the increased demand; whereas where the opportunity to

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give freely exists alongside the buying and selling of blood, the number of volunteers falls sharply and can only with difficulty, if at all, be made good by increases in the amount of blood bought. This suggests that to pay some people for their blood does discourage others from giving it altruistically; or alternatively, that a purely voluntary system encourages altruism in a way that a mixed commercial–voluntary system does not. 66 If Arrow is right, the mixed system could increase the supply of blood by pulling in new sources without pushing out old ones. If Singer is right, the mixed system could reduce the supply of blood by introducing commerce into responsibility in such a way as to threaten the social cement. The Gift Relationship does not muster the evidence that would enable the reader to make a rational choice between world-views such as these. Read as a work of philosophy, however, there can be no doubt that it raises the moral tone of social-science debate.

(c) Community The search for community is a long-established quest in the nation that blazed the trail to market economics. Concerned lest Carlyle’s ‘Midas-earned Mammonisms’ should prove a threat to Burke’s intergenerational conservatism, British sociologists and economists have long been returning to Smith on ‘sympathy’ in a social context to find the embedding framework for Smith on self-interest through exchange. Not much attracted by the extremes either of self-immolation or of atomistic withdrawal, British authors have characteristically settled on the middle ground. Opting as they have done for a mix, they have recognised that it makes no sense to study interest without studying community which must be its home. Disraeli in 1845 had recognised that one nation, subjectively sensed, was the cultural bedrock of gain-seeking individualism: ‘There is no community in England; there is aggregation, but aggregation under circumstances which make it rather a dissociating than a uniting principle . . . Christianity teaches us to love our neighbour as ourself; modern society acknowledges no neighbour.’67 Alfred Marshall in 1873 had argued that economic exchange itself generates the social upgrading that integrates fellow citizens into a going concern:

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The question is not whether all men will ultimately be equal – that they certainly will not – but whether progress may not go on steadily if slowly, till the official distinction between working man and gentleman has passed away; till, by occupation at least, every man is a gentleman. I hold that it may, and that it will.68 Tawney in 1931 had called instead for the socialisation of the ‘commanding heights’ – and for the Welfare State: ‘Because men are men, social institutions – property rights, and the organization of industry, and the system of public health and education – should be planned, as far as is possible, to emphasize and strengthen, not the class differences which divide, but the common humanity which unites them.’69 The means was socialism. The end was more general – to protect and enhance the ties of membership and acceptance which situate British welfarism within the long-established British quest for love without evaluation in a market economy unable meaningfully to return to the tribe.

The complementarity between conservatism and liberalism, organic unity and factored-down purposiveness, is a long-established debating topic in a nation that has never wanted rising living standards and nothing more. Richard Titmuss must be seen as a contributor to that debate. The means was welfare. The end, more general, was equal esteem for equal citizenship: As I see it, the Good Society respects people as people in all their oddities and eccentricities and not according to their social class, income, wealth, family inheritance, religion or race. It does not condemn children to poverty and a bad education because of the mistakes or misfortunes of their parents. It does not treat black people any differently from white people. It does not set out to punish old people because when they were young they failed, voluntarily or involuntarily, to save for their old age.70 The Good Society includes and integrates. It does not rank ‘people as people’ by their Porsches their Versaces and their executive diningrooms. The Good Society, as Titmuss sees it, presupposes the restoration of the felt – and the sharing – community that was lost when urbanisation and industrialisation privatised the agrarian networks

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and the village responsibilities. Then ‘the support of the group fell away as production was transferred from the home to the factory; from the group to the individual’;71 and the result was a vacuum in which the disadvantaged were neglected when long-lived bonds gave way to discrete and autonomous calculations. Social welfare fills the void. The Welfare State supplies relief of distress without a paid-for contract or the stigma of charity. It also strengthens the collective identity which in its turn defines the nation’s obligations and the individual’s rights. Linking welfare to the Good Society, Titmuss had no doubt that he had found an emanation that was at once an architect: ‘In my judgement, the National Health Service in Britain has made a greater contribution to integration and ethnic tolerance than brigades of lawyers and platoons of social workers.’72 Welfare to Titmuss was clearly not American welfare in the sense of means-tested cash benefits paid out to poor people. Welfare instead was a social contract that promised social rights solely ‘by virtue of citizenship’: ‘Universality, then, means the absence of social discrimination; the absence of externally imposed inequalities. The like need of each is of like value.’73 Welfare to Titmuss was an institutionalisation of equal access and equal respect, tangible proof that nation-building is ongoing and that to welcome in the outliers is simultaneously to reinforce the nucleus. Welfare to Titmuss was the warmth of Gemeinschaft in preference to the strict legalism of Gesellschaft in the stark juxtaposition of Tönnies, the ascription of status ranked above the achievement of contract in the familiar terminology of Maine. Welfare in short was community, where community is to be defined, following Robert Nisbet on affect transcending interest, as ‘all forms of relationship which are characterized by a high degree of personal intimacy, emotional depth, moral commitment, social cohesion, and continuity in time. Community is founded on man conceived in his wholeness rather than in any one or another of the roles, taken separately, that he may hold in a social order.’74 The image of national unity is an attractive one to conservatives of all ideological persuasions. What is less clear is whether social welfare per se actually merits the vitally instrumental role which Titmuss assigns to it in respect of social integration. Some theorists would build felt nationhood around a common monarchy; or a Manchester win over Spain; or universal military service; or the classless youth culture; or the common consumer culture. Titmuss

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concentrated on the experience of dependency. In so doing he may have exaggerated the power of the social services to lean against the prevailing winds. The National Health is not enough. The hospital can integrate boss and worker in the same ward and offer them free-on-demand access to common-standard care. In the treatment setting it can deliver levelling and even some friendship along with the laser and the scan. In the world outside its capacity to ensure unquestioning tolerance and permanent brotherhood must be that much more restricted. Boss and worker will not retain the amicable sensation of a common condition when they are restored to market-sector differentials in pay, power, prestige, security and facilities, when they resume their zero-sum struggle for relative shares in the process of collective bargaining. Here there is a fundamental contradiction between market value and citizenship value since a social gap opens up in the former case which is unknown and irrelevant in the latter. Titmuss writes that a Health Service should serve as an ‘expression and reinforcement of national unity’.75 A more sceptical view would be that it is essentially a universalisation of best-quality medicine; and that class identity and fissiparous exchange are likely to remain obstacles to felt community which even adjacent hospital beds are most unlikely to be able to overcome. Nor is the educational system the core and not the periphery. The teacher may treat all children equally and still fail to inculcate a lasting perception of social equality: after all, in a dual society, the market outside the school will ultimately grade and class his products (not least according to their relative efficiency in performing the very operations he has taught them). Merited rather than equal finishes are the market sector’s definition of social justice. This leaves little room, as Marris and Rein explain it, for the schoolteacher’s notion of fairness as equal commitment: ‘The schools cannot care equally for the education of every child, whatever his skills, unless the man he will become is equally valued, whatever he can contribute. And this no competitive economy can itself ensure.’76 Equality of opportunity need not mean equality of outcome – or of income. It can effectively be an architect of social distance and thus of malintegration in its own right. This is certainly the case with education where, as Titmuss himself concedes, scarcity of resources limits the supply of the most valuable forms of training and necessitates the rationing of places by intellect: ‘The principle of universality cannot be applied to higher education in any country

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of the world in this century.’77 Credentialism, as Titmuss recognised, is rampant. What remains to be defined is how to protect those responsible and hard-working citizens whose contribution is manual rather than mental from the contempt of their more intelligent former neighbours who have travelled further and faster because of the Welfare State. Free comprehensive schooling may clearly have an unintended dysfunction where welfare reshuffles the chances while the market continues to assign the higher wage to the bettereducated meritocrat. As with health and education, so with income maintenance. Titmuss draws the bulk of his examples from the arsenal of benefits in kind. Benefits in cash tell a different story. Earnings-related transfers in particular can be divisive to the extent that they carry over into the welfare sector the market sector’s definition of the just reward. A redundant executive will suffer acute loss of self-respect if he and his family must adapt to living standards significantly below those of his reference group. Earnings-related instead of flat-rate payments have the great advantage that, empowering accustomed levels of conspicuous consumption, they rescue the high-flyer from stigma and loss of face. That much is true, but so too is this: differential payment is another way of saying that social welfare buys a first-class ticket for a first-class gentleman and a second-class ticket for a fifth-class lout. The same threat of divisiveness arises in the case of earningsrelated pensions. Titmuss showed a certain myopia in welcoming the Labour Government’s National Superannuation Bill. That proposal would have carried the market valuation of the low-paid beyond the age of retirement. It would (magnifying the fact that the lowpaid are less likely to receive occupational pensions) have contributed to the perpetuation of ‘two nations in old age’78 that Titmuss was so eager to terminate.

Integration can be impeded where welfare protects the privileged. Titmuss was in no doubt that the middle classes were disproportionately represented in the social subsidy. Inclusion is a good thing – not least because means-testing and separate structures make the deprived feel like lepers whom no one will touch: ‘Those who use the minority public services come to feel that they represent a “public burden”; they cannot respect themselves nor do they respect others for using a public service.’79 It is a great advantage of common

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facilities for equal citizens that the deprived are spared the temptation to boost their self-respect through limiting their take-up. With the benefit comes, however, a cost. As was shown in Chapter 9, welfare can mean a redistribution of burdens such that a bus-driver pays for a doctor’s children to obtain an MBA in Finance. Inclusion in such circumstances can lead to resentment and not to the integration it was intended to produce. Titmuss identifies two areas in particular where the idea of a ‘Welfare State for working classes’ is simply ‘a myth’.80 The first is social services in kind: Contrary to much opinion, it is the professional and middleclasses who . . . have drawn more heavily and more successfully upon the high-standard, high-cost sectors of the social services. The total life advantages and earnings, for instance, of a successful, heavily subsidised, school, university and professional education at the expense of the community is worth, in material terms alone, a thousand times more than any number of national assistance grants, unemployment or sickness benefits.81 The second is tax reliefs and tax exemptions. ‘Pte. occpn. pensions. Now the costliest element of pension subsidy to the taxpayer. Much more costly than N.I. In 1956/7: Pte. occpn. pensions (ex public) perhaps £150m. a year, N.I. £70m. On what principles of social policy should this subsidy be paid by taxpayers?’82 Anthony Crosland had made it the prime end of the Welfare State (an end which he ranked above social equality per se) to level up the deprived: ‘The ultimate purpose of the social services . . . must surely be the relief of social distress and hardship, and the correction of social need.’83 Julian Le Grand, confirming the contentions of Titmuss, found that the impact of welfare had been instead to favour the already-arrived: ‘Almost all public expenditure on the social services in Britain benefits the better off to a greater extent than the poor . . . As a result equality, in any sense of the term, has not been achieved.’84 Titmuss was determined that equality should be achieved. On the side of benefits he recommended selective discrimination and educational second chances. On the side of costs he proposed graduated contributions and the reduction of tax allowances. His world-view would be compatible with medical research targeted on minority-

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group complaints; the phasing out of mortgage interest relief; the subsidisation of inner-city bus routes at the expense of stockbrokerbelt rail links. What his universalism could never accommodate would be stringent means-testing to keep out the well-to-do or systemic supplementary insurance to reduce the burden on the National Health. As long as universalism is an exercise in nation-building, the logic is correct. Should welfare be only marginal to Gemeinschaftmaking, however, it might not be unwise to economise on community in the sense of Nisbet in order to ensure that assistance and empowerment are disproportionately concentrated on those who are the most in need.

The poor are still with us. They are with us worldwide: ‘Over last 10 years Gap growing wider – rich countries per head income growing twice as fast as low income countries. Relatively speaking, rich are growing richer – poor are relatively poorer. But also in absolute terms (Pearson Report) 1950–67.’85 They are with us at home: In rediscovery of poverty in the USA and Britain in the late 1950s, men came to learn GNP was not solving poverty . . . In Britain came to be seen the Welfare State was not solving poverty . . . ① No change in wage/salary differentials. ➁ Wealth – 1960 – 5 per cent own 75 per cent of all personal wealth. ➂ Educational opportunities – massive increase in opportunities but little change in ppn. of sons/daughters getting higher educational opportunities.86 The poor remain a problem. Neither growth in the perspective of Crosland nor welfare in the vision of Tawney has succeeded in assimilating the poor. Titmuss was aware that absolute deprivation survives. The examples he gives include old people, the mentally and physically ill, unmarried mothers, deserted wives, workers on low incomes (especially those with three or more children). It is not just in the low-income countries, Titmuss appreciated, that rats and lice put the baby at risk, that malnutrition, hypothermia, tuberculosis, homelessness and hopelessness make existence as hand-to-mouth as it was in the East End of Samuel Barnett and Charles Booth. In 1960, Titmuss estimated, as much as 15 per cent of the British population was still

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living in ‘serious poverty’ as if guided by the classical economists’ subsistence wage: ‘In many ways remarkable. After 15 years of Welfare State . . . No income revolution. Not reaching the poor.’ 87 Even so, Titmuss argued, the iron law in the affluent societies was steadily being repealed thanks to the intervention of the invisible hand: ‘In all large-scale industrial societies standards of living have risen greatly during this century. Poverty today is not what poverty was at the time of Rowntree’s first survey in York.’88 Misery in the past meant absolute squalor. Distress in the present is more likely to have a comparative dimension: ‘Today, we are more concerned with relativities – with states of relative injustice; conditions of relative need; questions of relative choice and opportunity.’89 Poverty in the past meant no money for food. Poverty in the present is more likely to mean no television and no VCR. Galbraith captures the stigma of falling behind the norm in the following definition of what it means to be unacceptably poor: ‘People are poverty-stricken when their income, even if adequate for survival, falls markedly behind that of the community. Then they cannot have what the larger community regards as the minimum necessary for decency.’90 Titmuss, like Galbraith, is attracted by the idea of an interpersonal minimum that is the precondition for full membership in a history-specific collectivity: ‘To say that universality meant “freedom from want” is to say practically nothing because the phrase is meaningless if divorced from a given social context; from differential levels of living to which people have become accustomed and which they desire to maintain for themselves and their families.’91 Titmuss writes that poverty is relative, both ‘in time’ and ‘to the standards of society’.92 It is this perception of the pauper as an exile that is the vital link between his defence of community and his welfarist levelling: ‘When we talk about poverty we are really talking about inequality in our society.’93 Galbraith and Titmuss are most definitely doing so. Whether the bulk of their fellow citizens will necessarily follow suit must be a great deal more problematic. It is by no means obvious that, in a demi-market society, altruism will be triumphing over egoism to such an extent that a taxpayer who cannot afford a house of his own will be willing to finance a council flat for a well-fed neighbour who runs a car. Nor should it be forgotten that, in respect of those popularly labelled as deviant (unemployed overbreeders addicted to drink and drugs are a plausible example) the average voter may well be less non-judgemental than the social worker in evaluating

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potential dependants who demand more from society without supplying more in return. The Titmuss model is a consensus model, forever at the mercy of ‘the expressed wish of all the people to assist the survival of some people’.94 Physical survival will arguably command a certain consensus: so long as want is defined, with Beveridge, as ‘lack of income to obtain the means of healthy subsistence – adequate food, shelter, clothing and fuel’95 there is a reasonable chance that wider society will stretch out the safety net. Social survival, however, must forever remain a storm-tossed craft. Sometimes society will think as Titmuss and Galbraith. Sometimes society will harden its heart to welfare as common culture that imposes an unacceptable cost.

(d) Legitimation Richard Titmuss, like all other mortals, had his dark nights of the soul. Especially in the last years of his life he seems to have sensed that the 1940s were running out of steam and that the yuppies and the tax-resisters of the ‘greed is good’ 1980s were even then planning their escape from the middle ground. Thus, answering the question ‘Why are they Poor?’ in a lecture given in 1970, Titmuss contended that they are poor because we no longer care: ‘Because we are a very Unequal Society . . . Because we are unwilling to Tax ourselves . . . Unwilling to forego wage claims . . . Unwilling to reduce our Demands for more and more Consumption Goods. Because we don’t really want a more Equal Society . . . Trade Unions a law unto themselves.’96 In the year of The Gift Relationship Titmuss seems to have been conceding that a nation of blood donors too can have a narrow and a selfish side. In 1972, in his last completed paper – his Keynote Address to the International Conference on Social Welfare at The Hague, eight months before his death – he once again voiced his concern at ‘the current disenchantments and discontents’ which, he indicated, made the current consensus so very different from that of his early LSE years: ‘Social workers in many of the developed countries are less in favour today.’97 Care is being crowded out. For that ‘the cost-benefit industry and the cult of management efficiency as well as the mass media denigration industry’ 98 must take a fair share of the blame. Titmuss in the last years of his life revealed a certain anxiety about the evolution of altruism. Even in the high tide of LSE

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welfarism, however, he could acknowledge that things could still go wrong. A good example of his nagging doubt would be a lecture dating from 1958 – the year of the Essays on ‘The Welfare State’ and two years after Crosland’s reassuring The Future of Socialism – in which he noted with regret that there had been, in Britain and other countries, a noticeable swing of opinion against some of the more comprehensive provisions of the so-called (and ambiguously called) ‘The Welfare State’. The war-time enthusiasms for such policies have waned as the reasons for social cohesion, for arbitrary individual sacrifices, and for a less differentiated society have become less crudely obvious and less acceptable in a wealthier society with rising material standards of living. This has been expressed, in Britain and other countries, in (to put it quite simply) a growing reluctance to pay income tax.99 It cannot have been easy to retain any real confidence in the perpetuity of Parliamentary welfarism for an author who was capable of penning a deeply disturbing passage such as that. Crucial to an understanding of Titmuss as a social thinker is, however, the fact that the pessimism is the exception and the optimism is the rule. Titmuss was confident that the will would produce the way: his declaration from the very end of his career that ‘I am optimistic enough to believe that man can control his environment’100 is all but a repetition of his manifesto at the very beginning, that ‘just as man by his actions creates ill health and misery, so can man by his work create health and happiness’.101 Titmuss was confident that Welfare States would be the cause of states of welfare: ‘Tramps and vagrants and others without a settled way of life are a disappearing race’,102 he wrote in 1952, and, while ‘we still have with us our so-called “problem families”, . . . my impression is that the proportion is much lower than it used to be’.103 Titmuss was confident that most people are honest and decent most of the time: self-policing claimants validate non-judgemental attitudes, sensitive politicians are responsive to client pressures, accountable bureaucrats are conscientious, fair-minded and well informed. Titmuss was confident that integration would be brought about by welfare: ‘Titmuss stresses the divisive force of the market’, Wilding observes, ‘but assumes that social policies can combat such a powerful force. That seems prima facie optimistic.’104 Indeed it does. Titmuss, trying

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to be constructive, tended to look on the bright side, to find welfare socialism as effect and cause.

Confidence is the bedrock. It is also a black box and a hostage to fortune. Social welfare in Titmuss’s world-view is legitimate only where it reflects ‘the expressed wish of all the people’,105 where it actualises the ethical inheritance which makes us what we are: ‘The social services, as means and not ends, thus mirror the kind of society we choose to live in to-day and, in even stronger colours, the kind of society in which we lived yesterday.’106 Confidence is the bedrock – since social welfare in Titmuss’s world-view loses all its oughtness in a fallen community where consuming has vanquished caring and the winner takes all. Confidence is also a question mark and a cause for concern – most conspicuously so in the post-scarcity economics of Keynes and Galbraith where deprivation relates to air-conditioning and not to loaves of bread: ‘We can no longer rely as heavily as in the past on an alliance between hunger and socialism.’107 The problem is that Titmuss was content to take his black box on trust. Convinced that the British Welfare State, historically speaking, had bubbled up from the collective consciousness, he nowhere provided a rigorous and complete explanation of how social values are created, how shared perceptions come about. The omission is not without precedent. Tawney, Professor of Economic History at the LSE, documented the agrarian deracination of the Tudor enclosures but not the industrial impoverishment that had led him first to the Ratan Tata Foundation and later to Equality. T.H. Marshall, originally a tutor in history at Trinity College, Cambridge, theorised extensively about the matrix of rights within the hybrid of ‘democratic-welfare-capitalism’108 but resisted the temptation to trace the untraceable in respect of shared ought-to-bes and their cumulative causes: ‘It is impossible to say exactly how these ethical standards arise in a society or are recognised by its members.’109 Titmuss, it is clear, was standing on the precipice with giants. The company was distinguished; but it was a precipice for all that. Titmuss never developed a theory of the evolution of welfare. Confident as he was about the future, he chose none the less not to invest extensive study in an understanding of the past. Yet the author of Problems of Social Policy had too much of the historian in his blood completely to pass over both the institutions and the perceptions that gave rise to the institutions without any hint at

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all as to the social facts that had brought them into being. Discrete hints are not a theory of causality. Even so, they do provide a basis on which others can usefully build.

Titmuss saw social welfare as a response to economic modernisation: ‘The social services (however we define them) can no longer be considered as “things apart”; as phenomena of marginal interest, like looking out of the window on a train journey. They are part of the journey itself. They are an integral part of industrialization.’110 An ‘integral part’ is a structural necessity even before it becomes a conscious choice. Welfare in such a perspective becomes the inevitable concomitant of the momentum inherent in matter. It is an offer that a post-traditional society cannot afford to refuse. In the pre-industrial peasant community there was a welfare role for the extended family, the parish poor-box and the Lord of the Manor but no ineluctable need for a Welfare State: Society did not demand an educated peasantry; it did not demand a thousand-and-one labour skills; it did not demand a high level of fitness for work; it did not create conditions in which accidents, injuries and physical infections and diseases could plunge a family into poverty and misery; it did not demand that men should suddenly be retired from work at a certain age; it did not create immense pools of unused-unemployed-labour; it did not make the mentally defective, the disabled and those of sub-normal intelligence a menace to themselves and to society; it did not demand from parents a required standard of child care; it did not concern itself directly with how the members of a family behaved to each other and whether the family was reproducing itself or not.111 Titmuss’s account of the benchmark village is too simple: his Merrie England has no place for the underemployed labour, the contagious diseases, the avarice of the money-lenders, the indifference of the landowners, the costs of hospitalisation, the low level of skill that perpetuates a low level of productivity in the less-than-Merrie villages of the present-day Third World. Taken as an ideal type and a limiting case, however, Titmuss’s benchmark of organic England before the Fall does arguably support what he uses it to show: where needs are basic, church, charity and kindred are well placed to cope.

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The Industrial Revolution shattered the mould. Geographical uprooting meant that the supportive role of family networks and local communities came under threat in the impersonal anonymity of the urban environment: there was then no reliable option but the State for the poor and the at-risk who could not pay for private care and knew that cyclical unemployment was an uninsurable contingency. Factories and mines meant new health hazards for the breadwinner upon whose wages the family, no longer able to supplement its diet with the produce of its farm, became totally dependent: the social interest in geographical and occupational mobility and in the prevention of disastrous epidemics led in consequence to public action in defence of the stake. The upgrading of skills and the premium on formal education meant that the spillover commitment to training and retraining had to be made through unprecedented social involvement in the formation of human capital: the sheer speed of technological innovation and advance pointed to displacement for some, stress for all, and therewith a new role for the State in managing labour-market flexibility while minimising the social and private costs of insecurity and waste. Damage done, complex skeins, unidentifiable tort-feasors and remote interdependencies meant that the community had to act as a whole if permanent economic transformation were not to be braked by inequitable diswelfares that lie where they fall: ‘Somehow or other society has to find and devise forms of compensation – of support – of prevention – to counter the “disservices” and “dependencies” resulting from change. The “gales of creative destruction” (to use Schumpeter’s words) have to be matched by agencies of social equilibria.’112 Public services result from private disservices. That is the way it has been ever since the Industrial Revolution swept through Merrie England and shattered the mould. The economic structure went through a revolution; and so did ‘the character and amount of social need’, ‘violently changed by a change in society’.113 Writing of the new imperatives for which the old palliatives had revealed themselves to be ‘totally inadequate’, Titmuss makes clear that he is a sociologist whose concern is with the sum: ‘“Need” is no longer a simple, individual concept; it is now seen to interlock with the needs of society as a whole.’114 The focus has become the matrix – and the relationship is now ‘seen’ to exist. Titmuss always argued that underlying structures had little or no explanatory significance in sociology so long as they were not refracted through the meaningful subjectivity of values and

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perceptions. His interpretation of social need is in that sense a dual one. Titmuss sets out ‘to state the character of past and presentday social needs’, but also to do something more – ‘to explain how it has happened that society has, at least in part, recognised the existence of these changed social needs and has, through the agency of central and local government, accepted responsibility for meeting these needs’.115 The task of uncovering the needs is a difficult one. The task of accounting for the attitudes is a more difficult one still. Difficult or not, the attitudes must even so be explored. It is seen structures and not hidden structures, after all, that form and shape the legitimating consensus. Titmuss strongly rejected the economic determinism of unavoidable complementarity, the ‘notion of historical inevitability’116 which leaves no room for moral choice. Social policy, he insisted, is not value-neutral; and there cannot for that reason exist a unique developmental path to which all countries are compelled willy-nilly to adhere. As proof that societies have the same freedom to reject the Welfare State that they do to select it, Titmuss repeatedly contrasted the experience of the USA with that of Britain, de facto ‘Right and Left’.117 The British chose the National Health. The Americans chose the American Dream. Industrialisation is the necessary condition. Social consensus is the sufficient condition. The two conditions are not the same. The absence of institutional convergence is the proof that the human will still has a value.

Britain chose the National Health: ‘The British, in inventing the Health Service . . . made a contribution to civilized living; an example to the world of how social values, respecting the dignity and liberty of sick people, might be incorporated into the fabric of society.’118 Britain made good-neighbourliness the duty of the Welfare State: ‘A heightened sensitivity to the pains of others implies a heightened sense of felt responsibility for its alleviation and removal.’119 The British did and the Americans did not. The key question is why. Never very detailed about sunk bygones that do not start from here, Titmuss gives several instances of social causes that made the British response quintessentially itself. One of these was the ‘no man is an island’ solidarity of the British working class. Whereas the capitalists’ world-view eulogises rivalry, individualism and confrontation, history reveals that

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the working-class ethic was in all respects opposite: difficulties are to be overcome not by competition but by combination; if a man falls he is to be helped; not for charity but because he is one of us, and we cannot do otherwise than help him; if he is a poor or slow workman it is not for better men to degrade him by passing ahead; the pace must be adjusted so that all can maintain it.120 The working-class ethic is a stimulus to assistance and a deterrent to aggression. The very term ‘friendly society’ is a reminder that the self-help club preceded the Welfare State in the new urban communities where the poor and the vulnerable had no friends but each other: ‘Positively it expressed the idea – surely a Christian idea – of mutual, neighbourly help in the contingencies of industrial, city life; negatively, it expressed the work-class loathing of a harsh poor law and authoritarian forms of charity.’121 The friendly society, the trade union, the local community institutionalised the welfare principle from below. The Welfare State to that extent only nationalised a going concern. A second causal influence on the British welfare ethos was ‘the educated man’s tradition of public service’.122 Humanitarians and social reformers like Florence Nightingale, Charles Booth, Octavia Hill, Lord Shaftesbury, Sidney and Beatrice Webb had demonstrated by their example that the prosperous are bound by noblesse oblige to put something back: instilled in them had been ‘the belief that they were educated not solely in their own interests but for the benefit of society as a whole’.123 They were discontents, ‘rebelling against the excesses of a philosophy of unbridled individualism’.124 More significantly, they were advocates as well, the proponents of a constructive alternative that went beyond the unfocused destructiveness of angry tearing down: ‘The fundamental reason why they were successful is that they were based not on hatred but on a passionate desire for social justice for other people.’125 They conducted surveys and empirical investigations which documented the pervasiveness of absolute deprivation even before the Army medicals at the time of the Boer War confirmed that physical unfitness among the poor was the rule and not the exception. They set an example of voluntary service and social science which, in Titmuss’s view, led directly to the nationalisation of care that was to come. Most of all, however, it is a third causal variable to which Titmuss returns again and again when he seeks to explain the institutionalisation

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of altruism through the Attlee Government’s Welfare State. This is the catalytic effect of the Second World War, both in so far as it engendered the collective solidarity of the ‘spirit of Dunkirk’ and of the Blitz and because it led to welfare universality to absorb a citizenship-based shock: The idea of eligible and less eligible citizens rooted in the old poor law was swept away by a war in which all classes and all sections were involved. The public conscience would not accept an arrangement by which injured civilians and the wives and children of soldiers, sailors and airmen were accorded an inferior type of social service or subject to a test of means before certain essential needs were met.126 The war was the university that educated the consensus in the equalising policies that transcended the prewar distress: ‘The war could not be fought on this basis and it seemed to follow that they should obtain in peacetime as well.’127 The war reaffirmed the comprehensive principle which became the basis for the National Health: In many respects, the word ‘comprehensive’ is much the same as the phrase ‘fair shares’ – a phrase which we all associate with the Second World War. It was realised that we could not fight the war on the basis of unfair shares. Why, then, should we have one principle for war-time; another for peace-time?128 The war, in short, was a socialist experience which opened the door to the postwar socialism. The door, once opened, would not be shut again. The more sombre Titmuss in the more monetarist 1970s recognised that the cumulative inheritance of the Boer War and of the two World Wars could not realistically be expected to last forever: ‘Apart from the Suez episode in 1956 Britain no experience of war for 25 years. In the absence of war and the solidarities, the compassion, the “Garments of Hardship” (Winston Churchill), what takes its place as an ethical driving-force?’129 Titmuss believed that British people had learned to accept the ‘principle of national responsibility in time of war’130 who would not have gravitated to politicised collectivism in a non-war market. Titmuss believed that war more than any other causal influence had engendered the perception of

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the common condition that had led to the socialisation of provision: ‘War, as a total experience, has done more to shape the evolution of social policy in Britain – and to greatly extend the role of Government – than any other major historical set of causal agents.’131 Yet Titmuss also asked the crucial question of ‘What takes its place?’ His question opens a Pandora’s box of doubt in a welfare society that must consolidate its consensus without rattling its sabres. One could, of course, defend the welfare ratchet with reference to snowballing universalism itself: this would be the expectation that community-spiritedness supplied through the National Health leads to community-spiritedness demanded through the sweeping away of the public schools. One could, alternatively, predict that the electorate will continue to vote for compassionate free gifts because of the terrible selfishness of the unilateral vested interest: where Tom becomes accustomed to cheap skilled labour from nationalised vocational training, where Dick gets used to rent rebates and cash allowances for dependent children, where Harry welcomes the safety net as a Rawls-like guarantee of public insurance even for moral hazard, there unbridled lust will fulfil the same function as good fellowship expressly because it converts the social services into an unexpected topic in gain-seeking capitalism. Titmuss was sympathetic to the idea that the welfare services keep alive the momentum that was engendered by the external threat. He would have been much less sympathetic to the notion that the demand for welfare is perpetuated by the determination to take without giving. Be that as it may, his theory of the consensus that regards social duties as highly cherished rights must be amplified and extended if it is to identify the full range of causes in time and space. America had war without welfare. Sweden had welfare without war. War is not enough.

Titmuss neither produced nor set out to produce a single causal schema that would account at once for America and Sweden, for Bismarck and Bevan. Titmuss was an English author. In describing the relationship between welfare and war, Titmuss knew that he was writing about his own country and not about the whole of the race. Durbin was never comfortable with holidays abroad. Tawney habitually spoke of his ‘fellow Englishmen’ and not of his ‘fellow human beings’. Beveridge all but pointed with pride to his Empire childhood when he said that, in providing social security against

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the five giant evils, ‘the British community and those who in other lands have inherited the British tradition have a vital service to render to human progress’.132 Titmuss was a heartlander and not a cosmopolitan in the world of welfare. Clearly, however, he was not the only English welfarist to feel at home in the culture of his birth. Hilary Rose has correctly identified the cultural nationalism, even the cultural patriotism, that is the tacit assumption in so much of Titmuss’s work: ‘Being English was for Titmuss’, she writes, ‘stronger than his feeling for class. The inequalities of class were to be rectified in the name of the larger community of England.’133 Titmuss’s two greatest monographs bear out her assertion. Problems of Social Policy tells how English people from all walks of life came to act as one in the service of communal values and a common place in the sun. The Gift Relationship proves that British altruism succeeds where both American capitalism and Soviet command have failed, in making possible the chance to live. In both cases the community is not the class but the nation. In both cases the mood is self-congratulatory and the socialism another name for Ambridge in the pub or at the sponsored swim. Rose recognises that Titmuss is in the tradition of the socialists of sentiment like William Morris who had so much in common with the non-socialist conservatism of Burke, Carlyle and Disraeli: ‘His critique of capitalism was at one with that strand of English socialism which seeks to restore the old bases of gemeinschaft in the family and the community, whose distaste for the market is that of the patrician, whose feeling for the sufferings of the people is that of the good squire.’134 Belonging is irreducible. Exploitation is a footnote. It is a view of the world which, treating socialism as inclusion, looks askance both at class conflict and at market haggling because they disturb the peace. It is a perspective which is widely shared in England even by people who have never thought consciously about the contents of their ideological baggage. Titmuss’s sociology recalls the ‘aristocratic sense of responsibility’135 which led the privileged into philanthropy and good works. It reflects the salience of clubbing together (where conscience precludes free-ridership because cheating isn’t cricket) and of the middle-ground compromise (since a nation that fears the stridency of extremes will have a tendency towards the mixed economy of altruism and exchange, public and private, convention and opportunism). It does not, on the other hand, evoke the rather different

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mindsets of unconstrained individualism (including the tradesman’s principle of ‘private vices, public virtues’), codified legalism (social attitudes serving as a far superior bill of rights), public-choice politics (politicians and bureaucrats are taken to be imbued with a public-service ethos) and closed-door exclusivity (Titmuss opposed the Commonwealth Immigration Bill of 1961 on the grounds that it was racist and unfair). In what he opposed as in what he supported, Titmuss was in touch with a complex of resonances which would not have been unfamiliar to the representative Englishman in an England which the tourists still expect to find.

English values made an implicit contribution to the groundswell of opinion that legitimated the universalism of welfare. So too, albeit even more implicitly, did the Christian faith. The conclusion is a surprising one, partly because Marxism makes socialism the corrective to religion, partly because Titmuss, as Ann Oakley recalls, thought of himself as an ‘agnostic’ (but not an atheist) and not as a Christian at all: My father was never open about his attitudes to religion but I can say quite confidently that he did not share the High Church Christianity espoused by Tawney. He found religious ritual showy and offensive and never personally went to church . . . I used to ask Richard about religion a lot. These conversations definitely indicated to me that he held no belief in any sort of God at all. On the other hand, he was a very moral person, and some of his moral values, being espoused with great rigidity at times, could have had the appearance to others of deriving from a religious faith.136 Others, certainly, have spotted the resemblance. Thus Trevor Huddleston, speaking at the memorial service, described Titmuss as a ‘true Christian’;137 while Robert Pinker, noting that ‘in many ways Titmuss inherited Tawney’s ideals of a new socialist commonwealth’,138 finds that the New Testament binding is by no means absent even in the work of an author uninclined to appeal to the Bible. Pinker writes: ‘Tawney’s socialism was deeply imbued with Christianity . . . Whilst Titmuss was ostensibly a secular thinker there are many parts of The Gift Relationship which have close ethical affinities with the traditions of Christian socialism.’139 The Gift Relationship – and all

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the other books as well. Even if Titmuss had no belief in any sort of God, he had clearly absorbed the lessons of Jesus that he shared with the majority of his fellow Englishmen. Jesus said: ‘Give to everyone who asks you’, ‘Be compassionate as your Father is compassionate’, ‘Do not judge and you will not be judged’. Jesus was accepting of the Prodigal Son, full of praise for the Good Samaritan, sharply critical of the rich man who intended to enter the Kingdom of Heaven. St Paul told the Corinthians: ‘A body is not one single organ, but many . . . If one organ suffers, they all suffer together.’ St Paul told the Romans: ‘Love cannot wrong a neighbour; therefore the whole law is summed up in love.’ No one, Christian or non-Christian, can grow up in England without internalising moral values such as these. They are easily recognisable in Titmuss on consensus and its legitimation. Titmuss flirted consciously with the language of religion: ‘sin’ is invoked, ‘communion’ used where ‘communication’ is meant. He had every right to do so. Richard Titmuss, who walked with social scientists, was a great preacher above all else.

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11 The Failure of the Market I: Quality

Titmuss believed that the quality of provision in state welfare systems is superior to that in private welfare markets. This can be inferred from three examples relating to health services. These are the quality of blood available for transfusion; the quality of professional attention received from medical personnel; and the quality of care provided by the general practitioner.

The first example is the quality of blood. In America in 1965–67 about one-half of blood collected (including blood obtained through plasmapheresis programmes) was purchased and a further 40 per cent tied by blood-insurance or blood-replacement contracts.1 This indicates, as was noted in Chapter 8, a low level of Smith-like ‘sympathy’ with the plight of strangers in distress. The future is grim. Voluntary donorship is on the decrease. There is an upward trend in the percentage of blood that must be bought from paid suppliers. Statistics are deficient, but it appears that the paid donorship is not a typical or representative cross-section of the community. A large percentage of the money-motivated appear to be poor, unemployed, unskilled, black and male, often homeless, often on drugs. They get by through selling their blood (at $5 to $25 per pint) to commercial blood banks and eventually to the rich, who can afford to write cheques for life-years.2 Unfortunately, these mercenary donors are often bled more frequently than accepted international standards would recommend. They thereby put themselves at risk from iron-deficiency anaemia (such last-ditch donors probably having an inadequate diet in any case). Moreover, the risk of transmission of hepatitis via contaminated 203

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blood is probably six to ten times greater if the donors are paid suppliers than if they are volunteers.3 Titmuss quotes evidence which suggests that in America hepatitis affects one in 25 to 50 patients receiving a transfusion, with death occurring in up to 20 per cent of these cases. Even if the fatality rate is less, still it is high: ‘There may be 75 000 cases of hepatitis yearly, with almost 10 000 deaths.’4 The number of cases is increasing. The emergence of AIDS since Titmuss conducted his research would seem to magnify the dangers. Commercial markets for blood, Titmuss believed, mean a high risk to the patient of disease, disability and death as a result of contaminated supply. Contamination is intimately linked to conflict of interest. A potential donor, recognising that a full medical history might disqualify him from giving blood and thus deprive him of money, is likely to conceal a history of jaundice, malaria, syphilis, alcoholism, drug addiction (possibly using unsterilised and infected needles) and to understate how often he has already been bled. Anyone who is willing to walk in and sell his blood in order to buy food, drink or drugs cannot be completely trustworthy. Yet the quality of the gift – whether the blood will prove beneficial or harmful to the recipient – must depend on the truthfulness of the donor, on his willingness to provide rather than withhold relevant information. In such circumstances, ‘one man’s untruthfulness can reduce another man’s welfare’.5 Where blood is effectively a consumer good, the commercial donor has a positive incentive not to tell the truth about himself and his health: ‘Because he desires money and is not seeking in this particular act to affirm a sense of belonging he thinks primarily of his own freedom; he separates his freedom from other people’s freedoms.’6 The social costs of such irresponsible untruthfulness are plain to see: ‘The dishonesty of donors can result in the death of strangers.’7 Even private blood banks, moreover, do not adequately screen donors lest they themselves lose money; and deliberate negligence or calculated carelessness as to the health of donors is only a step away from flagrant illegality (such as the use of insanitary equipment, or the mislabelling and updating of blood). Profitmotivated commercial blood banks may actually seek out downand-out donors (despite the obvious health hazards involved). Such donors charge less for their blood than a higher class of donor would have done; and every good profit-seeker has the incentive to buy in the cheapest market.

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The ignorance of the recipient as to whether blood is infected denies him his consumer sovereignty. The patient must trust the doctor who must trust the donor, since often the laboratory cannot identify diseased blood until it has been transfused into the recipient (de facto the guinea pig used to test its quality in conditions of medical uncertainty). Such trust is likely to be misplaced. In America, the consumer has less freedom to choose healthy blood than in Britain, and the payment is higher for the transfusion. In America, the patient ‘pays a far higher price for a more hazardous service’.8 The destruction of a system of unilateral transfers in a world of competitive capitalism may well mean the destruction of the patient’s life. In Britain, in contrast, blood is of good quality. In view of the potentially lethal nature of human blood and the risk of disease being transmitted, rigorous standards are maintained in the selection of donors. Health standards are set to ensure that the donor is a suitable candidate. At least as important is self-selection. The donor himself is likely to be truthful since there is no financial incentive to be otherwise: all British donors are volunteers making a free gift, in contrast to only 9 per cent of blood suppliers in the United States.9 Moreover, the system of large-pool plasma is avoided. It has commercial advantages in that such plasma is easier to store and transport than small-pool plasma, but there is also a greater risk of infection.10 As a result plasma in Britain has for some time been prepared from small pools of blood drawn from less than ten donors.11 British arrangements maximise the supply of honesty. They ensure that blood will be safe and pure precisely because it is not an economic good or the outcome of a utility-seeking sale. In Britain there is little or no risk of infection as the consequence of a blood transfusion.12 The reason is that the values of the economic marketplace are not applied in the world of social welfare. In Britain, in other words, ‘freedom from disability is inseparable from altruism’.13 The British system benefits the donor as well as the recipient. In Britain the donor is not bled more than twice a year (although he could safely be bled more often in an emergency), and thus his freedom is protected: there is no risk of iron-deficiency anaemia brought on by overbleeding. This danger is greatest for the poor and the underfed, who ought not to give blood in the first place but who, in a commercial system, may be attracted to do so by the promise of cash. A commercial system is ‘potentially more dangerous

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to the health of donors’14 than a public system of free gifts. The Welfare State protects the donor against himself.

Titmuss gives a second example of inferior quality in the private sector, namely inferior standards of professional practice. The reason once again is the conflict of interest, and specifically the threat to the doctor’s professional ethic that might arise in a market system. To begin with, it is necessary to note the existence of this ethic: In all Western societies it is declared that the supreme object of medicine is service and not personal profit. The essence of professional behaviour and the patients’ confidence in a profession is thus predictable service to people. Predictable, in this context, can be translated as ‘truthful’. Practitioners have a fiduciary trust to maintain certain standards predictable to patients.15 Doctors upon qualifying accept the Hippocratic ex machina to ‘help the sick’, to put patients first. Yet in a market system where the doctor has the attributes of a small businessman – an entrepreneur who sells his services to the highest bidder in the same way that another tradesman sells tomatoes or beetroot – the temptation is real to shape disclosure and diagnosis in such a way as to make it the servant of supplier-induced demand. Because there cannot be consumer sovereignty in a market where the patient lacks the specialist knowledge to make a rational choice, the patient must have confidence in his medical adviser. There is evidence that the doctor has often abused that trust for personal profit. A doctor who has invested in a hospital or pharmacy16 or who has staff privileges at a particular clinic such that he gets a percentage of the fee paid by each patient he recommends is likely to be tempted to prescribe unnecessary treatment. In a free-market economy buyer and seller are presumed to be on an equal footing. In the case of medicine, however, non-shared knowledge and information asymmetries in the sense of Arrow mean that the principal has no alternative but to trust to the expertise of his agent. The patient must accept that the doctor knows best and be prepared to sacrifice his freedom of choice to his respect for higher authority. The danger is that the doctor will abuse the confidence that the patient has put in him. The very fact that the future demand for medical care is unknowable in advance causes

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consumers, unable to plan ahead, to purchase health insurance. Such pre-payment may tempt doctors at the margin to err on the side of income by supplying the maximum that the insurers will allow: Their inability to make choices leads some consumers to demand ‘their rights’ written in partial prepayment contracts – X number of days in hospital, access to an expensive drug, three X-rays a year and so on. Similarly, some doctors put up their charges when they learn that consumers have already ‘bought’ particular units of service. A rise in the price of an appendectomy – which has been ‘bought’ but which may or may not be necessary – will cost the consumer nothing in the short run or until the policy comes round for renewal.17 Such ‘imbalances and distortions . . . must inevitably flourish in market situations in which science has increased the relative ignorance and sense of helplessness among consumers’.18 Witness, for instance, the situation in Mauritius, where the patient is often at the mercy of an unscrupulous pharmacist. There, ‘the pharmacist who is asked to prescribe at the counter is inevitably tempted to try and dispose not of the customer’s disease but of his own expensive and unwisely purchased stock’.19 Medical care is not a commodity like any other. Almost completely ignorant of the need for or quality of a particular service, the consumer cannot meaningfully be said to ‘shop around’. He cannot know whether he needs surgery to have his appendix or tonsils removed, or estimate how well the operation was performed. Nor can he normally benefit from evaluation of experience. The typical intervention is a once-for-all affair. The patient can only judge treatment once it is too late to rewrite the record. Such ignorance makes the doctor–patient relationship an unequal encounter. The inequality is if anything a widening one due to the scientific revolution. New drugs, new techniques, new instruments, new degrees of medical specialisation all represent not greater choice but greater confusion to the shopper who hasn’t a clue: ‘It is now impossible to explain medicine to a sick man, for it is as difficult to describe Hodgkin’s disease or acute leukaemia in everyday language as it is to find everyday words for a curve of the fifth-degree or the notion of entropy.’20 The problem of understanding is even greater where the patient is mentally retarded or mentally ill, educationally

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deprived or a new immigrant with a different value-system. Yet these consumers too have a right to good medical care. The market cannot satisfactorily provide what the consumer cannot reasonably value. Price competition in medicine is therefore not a viable proposition. By subjecting doctors to the law of the marketplace, a society distorts doctor–patient relationships, lowers standards of professional practice, and fosters feelings of cynicism, frustration and dissatisfaction among clients. In America, some indices of the palpable breakdown in relationships and standards are the following. First, there is information from attitude studies and surveys. For example: ‘A nationwide study commissioned by the American Medical Association in 1958 reported that 44 per cent of all the people interviewed had had “unfavourable experiences” with doctors, 32 per cent of them so unsatisfactory that they said they would not return to the same doctor.’21 Second, there is an increasing resort to self-medication. In the absence of the protection that is provided by ‘a relationship with a personal, generalized doctor the patient in the United States has increasingly to resort to self-diagnosis’.22 One consequence is ‘the growth of various forms of medico-scientific charlatanism, resort to the corner drugstore, chiropractors, naturopaths’.23 Consumer sovereignty in such a situation may come to mean the dominance of the makers and advertisers of drugs (and of the media, who generate dividends through the advertising). In another sense, of course, ‘it is the patient who has surrendered by worshipping uncritically at the shrine of science’.24 Third, there are a number of malpractice suits in the United States. It was estimated in 1969 that ‘one in five of all physicians in the United States had been or was being sued for malpractice’.25 The situation was particularly bad in Southern California, where ‘physicians in practice for five years faced in 1969 a 50–50 likelihood of being hit with a claim and the attendant threat of a lawsuit’.26 Such suits ‘are thought to be a symptom of a breakdown in doctor– patient relationships’.27 The rising incidence of such claims may be taken as testifying to the existence of consumer dissatisfaction with the standard of medicine in America. Suits have been filed if the patient had simply not been informed of every possible side-effect that could arise from an operation (and explanation is no easy task when a sick non-specialist is in need of surgery without delay), or if a miracle drug did not work. Titmuss says that the point is being

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reached where there will even be a suit if the patient does not fully recover or dies despite the fee. Malpractice suits necessitate malpractice insurance, the cost of which is high and rising. In California, to take the most extreme example, ‘the young doctor has now to pay around $820 a year for such insurance’.28 Even worse than the cost of cover is the danger of being without. A doctor unable to obtain insurance at all may be faced with bankruptcy. He in any case feels his career and his clinical freedom to be severely restricted. The patient, moreover, does not take out what the doctor pays in: ‘Commercial insurance cover against malpractice cost physicians approximately $75 000 000 in 1968 but of this sum awards to patients totalled only about $18 000 000. The difference went on sales and promotion, administration, profits and legal fees.’29 Neither doctor nor patient really benefits from such a set-up; and hence, in order to eliminate the middleman, compulsory arbitration is often agreed upon before commencement of treatment. Yet in this case the patient signs away his right to sue the doctor in the event of malpractice, and must also acknowledge the contingency of potential negligence at the very start of the doctor–patient relationship. Such a state of affairs is unlikely to breed an atmosphere of trust. Titmuss believed it was imperative, in the light of the above evidence on the failure of the market when applied to medicine, to resolve the conflict between the doctor’s professional ethic and his economic self-interest: ‘In the social situation in which the doctor finds himself today, I happen to believe that the conflict between professional ethics and economic man should be reduced as far as is humanly possible.’30 This can only be done by taking medicine into the state sector: I regard the National Health Service Act as one of the most unsordid and civilized actions in the history of health and welfare policy. It put family doctors on a footing with university teachers, and patients on a footing with university students. Both professional groups – of doctors and teachers – are expected to give generously of what they know without a premium being put on time or knowledge. The presumption in the relationship is thus more social than economic.31 In Britain, unlike the United States, there is no conflict of economic interest, and the doctor can be true to his ethic of disinterested

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service. This does not, of course, mean that he is expected to be indifferent to monetary compensation, only that his salary or capitation comes to him irrespective of interventions supplied. The result is that he in practice spends his time performing a series of unilateral transfers. Titmuss was aware of the role that monetary incentives could play in the Welfare State. He pointed out, for example, that ‘to attract, recruit and staff the social services . . . raises competitive issues of pay, rewards and career earnings’.32 He thus reminded the reader that higher taxes to finance higher welfare spending could reflect higher input prices rather than increased quantity of product supplied. Again, he noted that supplementary benefits staff are low-paid relative to the earnings of bank and insurance clerks, with the understandable result that ‘for years these offices have been understaffed while banks have often been overstaffed’.33 He is here speaking of administrators. Elsewhere, however, he attributed the same sensitivity to pecuniary incentives to medical professionals themselves. Thus he advised the Mauritians that the geographical spread of doctors in a coordinated national health scheme owes something to the fact that doctors respond to differential capitation fees by moving into underdoctored areas: Experience in other countries has shown that it is very difficult to induce doctors to live outside the main urban centres . . . We hope to solve this problem in Mauritius by the incentive method which is used in Sweden. We believe that doctors will be attracted to live in less popular areas by the offer of a free house and some monetary differential.34 On the other hand, he did recommend to the Tanganyikans that they should adopt a standardised national salary scale. Since he also argued that vacancies in Tanganyika should be filled by advertising, not compulsory posting, it would appear likely that unpopular posts would not be filled at all. Titmuss was aware of this danger: ‘We accept that such a system could result in the least attractive candidates getting the least attractive appointments and, occasionally, in vacancies going unfilled for some period.’35 Yet the report still makes no mention of differential monetary incentives. Whether a local scale or a national scale is applied, the principle remains the same: professionals’ pay in a public healthcare system should be independent of throughput, just as academics should not

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be paid according to the number of graduates that each has produced. Only then will doctors be free to exercise their professional curiosity and to pursue the supreme ethic of disinterested service rather than the mundane aim of profit. Such disinterested service is the guarantee of predictability, quality, and high standards of workmanship. The patient can with more justification put his trust in a salaried professional than in a tradesman paid by piecework; and such trust is an important part of personal freedom. In Britain, Titmuss insists, there is no breakdown of confidence in doctors. There were only 264 cases of alleged professional negligence in 1967.36 The subscription for malpractice insurance in 1969 (the same year as the cost in California was $820) was only £6.37 Moreover, appeal mechanisms are organised by the Service itself, so that recourse to expensive litigation becomes unnecessary. The greatest protection for the consumer is not the right to appeal, however, but the expectation that the doctor can be relied upon to give truthful information. Doctor as well as patient benefits from state medicine. In Britain, the doctor is freed from the dilemma of how to treat people who cannot pay. Due to the existence of the National Health Service, cost is no obstacle to care and the doctor does not have to ask himself if the patient can afford the optimal course (a specialist consultant, a drug, a spell in hospital, an expensive surgical aid, a series of X-rays). Such a system means enlarged professional freedom for the doctor, who becomes able to treat the patient according to medical rather than monetary criteria. There is more. The doctor in Britain has security of tenure; and can also count on a guaranteed income. He is thereby freed from financial worries such as how to compete with his rivals, or whether or not he will be able to attract enough customers into his shop without sacrificing his standards to the whims of the sovereign consumer. In a system of private medicine, on the other hand, practitioners are often forced by their patients into prescribing ‘useless and sometimes dangerous’38 medication: in a competitive situation, after all, withholding drugs might cause the physician to lose repeat business. Such was the situation in Tanganyika at the time of Titmuss’s visit: The people of Tanganyika now broadly accept the efficacy of Western medicine in its curative aspects. Indeed, there is a danger of too much reliance being placed on the drug and the injection. There is a growing tendency for patients to ‘shop around’ among

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various doctors and agencies in the urban areas in the belief that any and every ill will be cured if a powerful enough drug is obtained.39 The conjunction of modern medicine with the market mechanism is an explosive one: ‘It must be difficult, in these days of scientific drugs, to take money from patients and give nothing tangible in return.’40 Yet such patient pressures may represent an unhealthy and wasteful substitution of the curative for the preventive, and thus an incorrect attitude to the problem of disease. In Tanganyika, ‘as a result of the success of modern methods of treatment of yaws and certain other diseases, health has come to be regarded as a matter of being injected when sick rather than adopting radical changes in diet and personal habits’.41 A private practitioner who refused to supply a fashionable ‘wonder drug’ would soon find himself bereft of clients and fees. His British counterpart is much more fortunate.

A third and final example may be cited of the way in which the quality of provision in state welfare systems is superior to that in private welfare systems. This is the fact that the community in Britain benefits from a symbiotic relationship with the professional. The key in the medical field is the flourishing network of general practitioners. The scientific revolution has meant that medicine has become increasingly complex and increasingly subdivided. In America, the general practitioner is rapidly losing ground to the specialist. Such family doctors as remain tend to avoid personal involvements and ‘time-consuming human relationships’.42 This is deplorable: ‘More and more people may be losing an essential patient liberty – the advice, protection and defence which the general practitioner is in a position to give his patient.’43 Fortunately, in Britain, in contrast to the United States, the general practitioner still has a leading role to play. His functions in the British system of social medicine are four in number. First, the family doctor is a bridge between the patient and the specialist and hence a valuable safeguard against the jargon of science. He is a vital defence against narrowmindedness, standing as he does between his patient and ‘the excesses of specialized technocracy’:44 This role of standing between the patient, the hospital and overspecialization increases in importance as scientific medicine

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becomes more complex, more functionally divided and potentially more lethal. These developments are enlarging the need for the detached, non-specialist diagnostician – the doctor who can interpret scientific medicine and the process of diagnosis and treatment to the patient according to the circumstances of each case, and without any functional or financial commitment to a specialized area of practice.45 Like any other generalist, the general practitioner has a wide range of knowledge. He is thus an informed counsellor to whom the patientconsumer can turn for advice. Second, the family doctor knows the patient as a person and not simply an envelope of symptoms to be passed from one anonymous expert to another while too ill to be able to make personal contact with any of these learned strangers. The family doctor is a family friend – Titmuss exemplifies the mid-century’s complacency – who has known the whole person in health as well as in adversity. Knowing the patient in his own home and environment, the family doctor is less likely than an outsider would be to mistake the symptoms for the disease. Moreover, and perhaps most important of all, the family doctor values communication with his patient, a quality too often absent in the chilly departmentalism of modern in-patient treatment: The demands that people make on society are greater when they are ill than when they are well. Yet the advent of science has made it more difficult, in social and psychological terms, for the hospital as part of society to meet these demands. More science means more division of labour and more experts – more of the mysteries of blood counts, X-rays, test-meals, investigations, case history taking and so forth. These, in turn, mean more departmentalism and, all too often, more departmental thinking. As A.N. Whitehead warned us, the fixed person for the fixed duties in a fixed situation is a social menace. He is particularly a menace to the sick person who is more in need, rather than less, for explanation and understanding.46 Hospitals, evidently, have not always grasped that ‘courtesy and sociability have a therapeutic value’, as the following example of the ‘discourtesies of silence’ in one British hospital illustrates: ‘Drugs were given without inquiry or explanation; examinations were made

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in silence; infra-red lamps were set going without explanation; people left hospital without explanation. The barrier of silence seemed impenetrable.’47 Patients were simply not told what was happening and why. Third, the existence of the general practitioner ensures that medicine will be community medicine. The general practitioner is a member of the local community and is, via his own integration, in a position to ascertain the nature of local needs. He thus helps to increase the potential participation of the hard-to-reach, who neither articulate their problems nor ask for help. Their participation increases pressure on scarce resources without any increase in revenue to finance the service. This in itself is a welfare objective far removed from the world of profit maximisation. Universalism in social policy must refer to the take-up of benefits as well as to the elimination of the means test. Even in the era of the National Health medical care is free on demand only to those who request it, to people who are aware in the first place that they have a need and a right to treatment. The hard-to-reach must be contacted, helped to make choices between alternatives, guided round a complex world of welfare. Only in this way can the Welfare State become de facto comprehensive. Clearly, the family doctor plays a vital role in this process, a role which is strengthened where he links up with other local welfare workers as part of a team.48 This is already happening in Britain, where nowadays ‘society is moving toward a symbiosis which sees the physician, the teacher and the social worker as social service professionals with common objectives’.49 Via the coordination that only really exists in a system of state provision, the physician becomes part of a community-care network that also provides rehabilitation and training centres for the physically handicapped, short-term stays in hospital for examination or treatment, services for the mentally ill, the single-parent family, the disturbed child, the materially deprived, the aged. The key words here are collaboration, cooperation, communication, consultation, continuity of care. Such integration of services cannot but mean a better standard of care: ‘The accepted purpose of the health service is to treat the individual who has some malfunction in such manner as to restore him to health, and that must involve the individual’s mental, emotional and social functions as well as his physical functions.’50 Fourth, community medicine benefits not only doctor and patient but also society as a whole. Some of these benefits are primarily sociological in nature. An example would be the socially integrative

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effect of treating all patients alike rather than arranging them in a descending scale going from those most able to pay (and therefore the most deserving) to those least able to pay (and therefore the least worthwhile ‘in genetic or productive terms’51). Yet some of the gains are clearly economic, and resource-related. This is the case with preventive medicine. To the hard-to-reach patient, ‘blindness prevented is an enlargement of freedom’.52 To society as a whole, however, it is no less a source of freedom, since it circumvents later pressure on resources: ‘Humanitarianism can . . . lead to substantial financial savings; insofar as blindness can be prevented, economic resources may be saved on a large scale for many years if old people are helped to go on living in their own homes without the need for institutional care and other services.’53 A similar benefit arises from the control of infectious diseases. The general practitioner can, by helping to set ‘standards of behaviour’54 for other local professionals, raise the efficiency of the community-care network. He can, by rationing medical resources according to need rather than means, contribute to the maintenance in good repair of the labour force. Naturally, the benefits that arise from general practice are difficult to measure with precision ‘in the language of productivity or the economic market place’.55 Yet the inability to quantify should not be allowed to conceal the very real benefits that arise in a medical system which allows for more home visits and more community care. The general practitioner, then, has four valuable functions to perform in the British system of social medicine. Despite those functions, he none the less suffers from stigmatisation and selfstigmatisation brought on by the fact that he is less expert technically than the Harley Street specialist, the research scientist or the consultant in a major teaching hospital. Nowadays, there is growing esteem for the specialist in all walks of life, while ‘the generalist is too detached and indeterminate to be in favour in a world of professionalism and expertise’:56 Because those who specialize (who aim to fulfil a restricted determinate function) have a higher status in our society the general practitioner becomes more conscious of inferior status. He is the indeterminate man; the one who is more uncertain of his place in the scheme of things; who is uneasy because he has to spread himself so widely and has no special role to perfect; no special skill by which he may himself achieve higher status in his profession.57

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The general practitioner is aware of his diminished status. He also feels powerless, convinced that the authority of the coal-face has been undermined by the experts and the technology of science. Titmuss believed strongly that the generalist doctor had to overcome his insecurities through an increased awareness of the crucial role that he plays in society. Time as well as socialism, paradoxical as it may seem, is on the generalist’s side. Scientific progress means more than just specialisation. It also means that the general practitioner can now treat more complaints (in the home and the community) that would previously have been lost to the impersonality of the hospitals. Science, by giving the family doctor a new lease of life, thus plays its part in keeping the standard of social medicine high.

12 The Failure of the Market II: Choice

Freedom of choice is essential to people’s self-respect. Titmuss himself rated it highly: ‘As an individual . . . I would like to be sure that when my time comes my right to be eccentric in old age will not be eroded by busy, bureaucratic planners. I shall want some rights to some choice of services; not a simple confrontation between, on the one hand, institutional inertia, and, on the other, domiciliary inaction.’1 The Welfare State is justifiable precisely in terms of the need to defend the freedom of consumer choice. It is, of course, true that people cannot ‘shop around’ for social work support, medical care, education and cash assistance (at least in Britain) to the same extent that they can for shoes or cabbages in the private market.2 The consumer can, however, none the less press successfully for a meaningful range of choices: Choices may be offered, for example, within social security programmes as to alternative ways of calculating and paying social security benefits as of right. Choices may also be offered between benefits in cash and benefits in kind; for example, old people living alone or unmarried mothers on low subsistence standards and in poor housing conditions might prefer the security of residential accommodation to higher assistance payments. Choices may also be offered within services in kind; for example, the alternatives of medical care and welfare services for disabled people in their own homes or in institutions or a combination of both through the provision of day hospitals, night hospitals, homefor-the-weekend hospitals, day and night homemaker services, occupational centres, and so on.3

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In respect of pensions, the State could offer ‘options and choices as to the form in which certain benefits are paid; for example, mortgage advances at retirement age, earlier payment of retirement pensions in special circumstances, etc’.4 The state sector is more likely to provide a range of options and choices in response to consumer pressure than is the private sector. The reason is that, whereas nowadays both sectors are highly bureaucratised, the bureaucracy in the former sector is socially accountable while in the latter sector it is not. Two examples taken from Titmuss’s writings will serve to demonstrate the superior sensitivity of decision-taking in the welfare sector. The first example refers to insurance. The second concerns medical care.

Private insurance is a social problem. In Britain, Titmuss argued, little or nothing is known about how private insurance companies and pension funds actually exercise their power, despite the fact that as institutional investors they dominate the City and are the single greatest source of new capital. They are secretive and release little data on the current market values of their assets and hidden reserves. Nor do they reveal the precise goals of the handful of managers who exercise the power of decision-making on behalf of the mass of shareholders and policy-holders. The insurance industry illustrates clearly what is meant by economic and social power ‘concentrated in relatively few hands, working at the apex of a handful of giant bureaucracies, technically supported by a group of professional experts, and accountable, in practice, to virtually no one’.5 It is power that is centralised and yet power without responsibility. The community has no guarantee that it is being used to satisfy social-welfare objectives rather than the personal and private priorities of unelected and anonymous office-holders buried somewhere within the large corporations. The community is not consulted about the employment of the funds at the disposal of the huge institutionals. It has no alternative but to accept the choices made by corporate officials on behalf of the collectivity. Yet this leads to an unbalanced allocation of social resources, since the private portfolios are inevitably skewed in favour of capital gains, of dividends and of corporate growth. Insurance companies do not invest in the slums of Lancashire or in the dying coalfields of South Wales but in profitable undertakings such as office blocks and luxury flats in London. Such choices sacrifice

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both the welfare needs of society and the quality of the environment. They are made with an eye to private profit and organisational aggrandisement rather than social amelioration. These choices are made without consumer or social participation by business executives who are themselves hardly a representative sample of the British population: ‘Of 126 directors of 10 leading British companies in 1956, one-half went to Eton and six other public schools; most of them belong to a small circle of clubs among which the Carlton is the most popular; a high proportion are titled; and most have extensive connections with industry, finance and commerce.’6 In the private insurance market individual liberty is ignored: ‘There is no appeal machinery in this costly and bureaucratic system; no opportunity to speak up as there is in the National Insurance system.’7 The private system is totalitarian, lacks democratic representation, and offers few if any channels for the redress of wrongs. Yet wrongs abound. There may be lack of consultation (as where a pension scheme is not voluntary but compulsory and the employee insured cannot choose to contract out), lack of alternatives on offer (as where there is little choice of cover, of insurer, or between earningsrelated and flat-rate benefits), lack of full transferability on change of job (an obstacle to mobility and thus to economic growth in an increasingly fluid economy), lack of survivor’s rights on the death of the policyholder (a loss of accumulated savings and a cause of much hardship to the widow left behind). In any case, redress of grievances is only possible if people understand their status. There are in Britain no less than 65 000 different occupational pension schemes (each with its own rules and structure of benefits). It is unlikely that the consumer who has signed up to any of them is in a position to make meaningful decisions: ‘Millions of those who are members or ex-members of such schemes know little about their rights, benefits and expectations.’8 Even if there were a formal appeals mechanism in the private insurance market, confused consumers would not necessarily have recourse to it. Many abuses in the world of private pensions and insurance have been brought about by the twin economic factors of oligopoly and economies of large scale. Mergers and amalgamations have reduced the number of firms in the industry; and it is a characteristic of markets dominated by a small number of large participants that price competition tends to settle into respectful accommodation. Simultaneously, giant organisations have sought to reduce administrative costs by substituting group risk-rating for individual risk-rating

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and calculating premiums on a simple cost-plus basis: ‘Prices and policies have become more standardised over larger areas of group insurance; less subject to risk- and experience-rating; possibly more subject to power-rating.’9 The decline in the practice (if not the fiction) of individual risk-rating leaves many difficult cases without any cover at all (or may at least force them to pay an unjustifiable supplement) simply because they do not lend themselves to classificatory standardisation. Here ‘equity suffers in the conflict with bigness and those who suffer most are those who fail to fit neatly into pre-determined large-scale classes, categories and groups’.10 This is likely to harden ‘felt discrimination’11 and the sense of stigma. Unexpected and inequitable redistribution may arise within a scheme once a system of individual risk-rating (where individual premium is tailored to individual risk) is replaced by group riskrating (where premiums and risks are pooled on the basis of broad categories such as age, sex or occupation). Blanket cover is discriminatory in so far as it means that good risks pay for bad ones. Those who are classified in a system based on standardisation may in that sense have as legitimate a complaint as those who are excluded. The absence of individual risk- and experience-rating means that ‘the true social costs are not borne by the dangerous industries and causative agents’ and that ‘the “bad risks” are not charged the true market price. The poor in non-dangerous trades may thus be subsidising higher income groups employed in other trades. The poor, safe driver may be subsidising the rich, bad driver.’12 Again, the decline of medical examinations for life assurance means that the healthy pay for the unhealthy;13 and also that a healthy applicant in a statistically unhealthy occupation or racial group may inequitably be overcharged despite the individualistic underpinnings of the economic free market. In any case, ‘actuarial risk- and experiencerating in group insurance is today far from being an exact science’.14 Much regressive redistribution from the poor to the rich shelters under the pretence of equality of treatment. Suppose, for example, that pension benefits for all policy-holders are related to highest earnings in the final three to five years spent at work. This nominal equality conceals a serious injustice, since such earnings are maxima in highly paid non-manual occupations but not for lowpaid manual workers whose earnings may peak earlier in life. The practice thus ‘discriminates against manual workers whose higher earnings in earlier years are not reflected in their pension benefits’.15 Besides that, social change means that the low-paid have a higher

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labour turnover, and hence a higher propensity to lose all or part of their welfare expectations (i.e. their deferred pay, taken in the form of health insurance and pension cover). Benefits lost are then shared out among those who remain in their jobs or enjoy 100 per cent transferability. In this way ‘many private pension schemes, which include manual and non-manual workers, tend to redistribute claims on resources from lower-paid to higher-paid employees’.16 Furthermore, in calculating pension benefits average mortality tables are applied. Yet the higher occupational groups have on retirement a longer life-expectancy than the low-paid and hence draw out proportionately more in benefits even where premiums paid are the same: ‘The poor pay more in the private pension market because they are poor and are statistically treated as non-poor.’17 In summary, then, it was Titmuss’s opinion that choices in the private market for insurance are made by a small number of executives in a small number of organisations. These choices, he was convinced, are demonstrably neither in the social nor in the consumer interest. The situation in the state sector is quite different. There social security reflects the social interest, since publicly provided services are directly accountable to the collectivity and its elected representatives. Since nowadays, whether in the state or the private sector, insurance is provided not in the competitive markets of the elementary economics textbook but through huge bureaucracies, it is all the more urgent to substitute accountable political authority for the insensitivities of naked economic and social power. Faith in politicians and the public bureaucracy means the ability to plan (with the implication that reprivatisation signifies not just a flight from government but a ‘retreat into irresponsibility’).18 It means the ability to discuss, since more information is available about social than about private insurance. Finally, faith in politicians and the public bureaucracy means that social security can serve consciously chosen social goals. Many social choices cannot be made by the consumer even in the most flexible of markets. The use of social security to encourage married women to return to work, to compensate the redundant, to narrow the gap between rich and poor in retirement implies a set of choices which can only be made by the collectivity as a whole. Naturally, ‘as the “social” role of insurance has become more powerful the area of conflict with actuarial principles has widened’.19 But, after all, the private sector too has moved away from the principle

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of individual equity, away from the idea of taking out what the customer has put in. Some redistribution is going to occur in either case. The State must in the circumstances ensure that choices as to who gains and who loses represent social rather than minority interests.

Medical care, like insurance, confirms the superior sensitivity of the state-provided option. Medicine in the last analysis is a social science. It must ‘change in sensitive association with the changing needs of society’.20 That is why its administration and the structure of services that it provides must be planned but adaptable. In the interests of democracy, they must unquestionably be subject to social control. A market system is unable to assure this social control. The consumer’s ignorance means that he is unable to make intelligent choices. Nor, acting alone, is he in a position to make choices which involve the collective rather than purely the individual interest. Titmuss believed that social policies are irresponsible where they are ‘imposed without democratic discussion’ and ‘without consideration of the moral consequences which may result from them’.21 In Britain, he contended, responsible rather than irresponsible policies in the medical-care field appear to be the order of the day. This optimum results from the interaction of four groups of social actors. First, there are the consumers. In the National Health Service, the public is able to reveal its preferences; and consumer participation already has some successes to its credit in influencing choices made. Public opinion outside the hospitals has, for example, brought about improvements in the food served to patients and in the arrangements made for parents to visit sick children. 22 The complex administrative structure of the National Health Service has clearly not inhibited criticism in the past. The quality of treatment in the Service has notably been raised by the presence in it of the vocal middle classes: ‘Their continuing participation, and their more articulate demands for improvements, have been an important factor in a general rise in standards of service – particularly in hospital care.’23 Integration combined with active consumer pressure has meant a levelling upward in the standard of amenity. Consumers in the future are likely to be even more demanding because of ongoing embourgeoisement. Society may thus expect improvements in the quality of its health services to result

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from ‘the rising standard of expectations of medical care from a more articulate, health-conscious society’.24 Indeed, the spread of education and of ‘middle-class attitudes and patterns of behaviour’25 has already meant that there is ‘a tendency for more people to adopt a questioning and critical attitude to medical care’.26 One social fact leads to another: ‘As standards of education and living rise greater significance is attached to sensations of pain as signals of danger to the individual and his sense of self-preservation.’27 A better-educated population will be less and less subservient and disciplined, more and more demanding of improvements in the quality and quantity of medical services. Such popular criticism will be healthy for doctors as it stimulates professional self-examination: For too long, university teachers outside Oxbridge, family doctors outside Harley Street, workers in other professions, and bureaucrats in Whitehall and Town Hall have lacked the challenge and incentive of a critical clientele. In this setting of unequal relationships, low standards have flourished. In the long run, an educated public opinion is, as J.H.F. Brotherston has said, the most powerful ally of the medical profession.28 Politicians and administrators must be made aware of the options that the consumer would like to have. These demands could usefully be channelled through the ‘institution of consumer advisory groups and the development of local committees and tribunals to hear complaints, to redress wrongs and to criticise administrative agencies’.29 It is, of course, precisely this opportunity to advise on the nature of his preference patterns that the consumer so much misses in the private sector. With the aim of consultation in mind, Titmuss recommended in Tanganyika that an Area Hospital Advisory Committee should be set up in each region: The regional medical officer or his deputy would take the chair and the members might include the area medical officer, one or more representatives of the local authority, and a representative of the local community development agency. All meetings of the committee would be attended by the medical superintendent, the chief nursing officer and the administrative assistant. We do not envisage such committees meeting frequently (perhaps once

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every three months) but we regard such a committee as a valuable means of co-ordinating the area health service, quite apart from providing local democratic representatives with opportunities to participate in the responsibilities of hospital management.30 In view of Titmuss’s conviction that decision-makers should follow as well as lead the consumer, these recommendations are surprisingly modest. One notes, for example, that the committees are to consist chiefly of professionals and that not consumers but officials are to be represented. Groups select groups: corporatism and not factoring down is evidently the democratisation that is intended. One notes too that the committees are to meet infrequently and to have no more than advisory powers. Of course, demand-led change is difficult to implement in a country where the bulk of the population is uneducated. Yet it is striking that in his work on the British National Health Service, Titmuss hardly mentions consumer participation via committees and councils at all, and appears to be extremely dubious of the efficacy of such outside interference. His view seems to have been that there is no substitute for a technical, administrative or professional background if one is to find one’s way round the complexities of the modern hospital system: I do not wish to join with those who would make a mystique of administration, but I must say that in my experience most lay members, newly-appointed, of a hospital board or management committee are pretty useless during their first year of office . . . It is not until perhaps half the three years have gone by that a new member can play a really useful part in hospital government.31 Whatever his views on direct participation, Titmuss unquestionably believed that the consumer interest should be taken into account wherever possible, and that institutional arrangements should be such as to guarantee freedom wherever freedom made clinical sense. Such freedom obtains in the National Health Service. In Britain the patient is free to have a private as well as a National Health doctor; to choose his general practitioner and to request a change; to select between treatment at home and treatment in hospital. The consumer has the freedom to seek treatment he could not otherwise have afforded (a valuable benefit to the less-affluent client whom the private sector is likely to reject because his needs are excessive relative to his economic power) or might have had to postpone

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(possibly until a need for prevention is superseded by a need for an expensive cure). The absence of a money nexus between doctor and patient heightens cordiality and gives the patient the security of knowing that proper treatment will be provided regardless of how much (or how little) it costs. Again, the integration of medical care in a comprehensive Welfare State means the removal of other uncertainties related to medical care. Thus, for example, since society provides not just hospitals but income maintenance in convalescence to its members, it permits the ill to enjoy the luxury of not returning to work too soon after treatment. Such a luxury is an important part of the freedom of consumer choice. Second, there is the press and the other mass media. Titmuss believed they had a valuable role to play in disseminating information about the social services and in providing informed criticism of their operation. He also believed, however, that the mass media were not properly fulfilling these functions because of their generally hostile attitude to the Welfare State, coupled with a tendency to trivialise great issues because simplifications sell more copies. These shortcomings of the media were due to their obsession with audience ratings (since these influence the sales of publications and the promotion prospects of journalists) and to a fear that support for government as against private enterprise would lead to a loss of advertising revenue. Once again, it is the profit-seekers who prove a disappointment to the team. Titmuss, naturally enough, does not propose nationalisation of the media. Indeed, he makes no direct recommendations at all on how to convert the media to the service of society, and only very indirectly hints at the need for controls of any sort. Yet the hints are there, and they come from the heart. The following is a case in point: Just as academic freedom can justify anything (what Tawney once called ‘creating a darkness and calling it research’), and clinical freedom justifies private practice and profit-making hospitals in the USA, so the freedom of the press can justify mass entertainment, the commercialisation of sex and the commercialisation of privacy. As these unlimited freedoms become more pervasive, society – and particularly at this point in history American society – becomes harder and harder to govern. It is not widely known that during the first six months of 1971 more people were murdered in New York alone than all the American soldiers killed in Vietnam during the same six months.32

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Titmuss believed that the freedom of the press, like other manifestations of the freedom to supply, had to remain within the tramlines prescribed by the social interest. If he was evasive about the precise way in which the press should be disciplined, it was because he was too much of a democrat to become an advocate of rigorous censorship. As with so many other socially minded liberals, what he would probably have wanted to see would have been a system of corporate self-regulation on the part of journalists and editors. Titmuss in the last analysis knew that he could not reasonably put control before self-control: ‘We have suffered and are still suffering from an irresponsible mass media, many sections of which seem intent only on cultivating cynicism. Not for a moment would I wish to curtail their freedoms; all I would ask is for some semblance of responsibility and some attempt to present the facts.’33 It should also be remembered that not all of the problems created by the freedom of speech could be traced back to journalists and editors who called underlying social values too blatantly into question. Doubts had been sown as well by prominent scholars like Milton Friedman and Herbert Marcuse, two authors whose work shares a common ‘critique of authority – and particularly authority in the shape of government’34 and who are both in part to blame for the threat to Big Government in the area of welfare services. Unprepared to curtail the freedom of the press, Titmuss would have been even less willing to curtail the freedom of academic libertarians, left or right, in order to limit the harm that their anti-statism had done and was doing to welfare. Titmuss, as with so many other socially minded liberals, had in the end to leave the grievance he identified without any early prospect of redress. Third, there are the medical professionals: ‘In the modern world, the professions are increasingly becoming the arbiters of our welfare fate; they are the key-holders to equality of outcome; they help to determine the pattern of redistribution in social policy.’35 The reason for this development is a technical one. A society does not choose to rely on the experts; it is forced to do so, since they alone can carry out quality control in an era of specialisation and scientific revolution. The expert does know better than the mass of the people. This means that in both private and public sectors decision-making by professionals inevitably challenges the primacy of simple consumer sovereignty. The problem is that the technocrats may also be insensitive. Professionals have greater power than ever before. The

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task must now be for society to make them ‘assume greater social responsibilities to match their added knowledge and the power that accompanies it’.36 Professionals, as expert as they are, are often resistant to social change because of their own financial interests; because of welldrilled inertia; or because of a fear that acceptance of criticism from without will diminish their prestige and influence and circumscribe their ability to control their own affairs. Professional bodies may, for example, irresponsibly obstruct the reallocation of economic resources according to social priorities by refusing to participate in drafting reforms and by rejecting the suggestions of outsiders: Criticism from without of professional conduct and standards of work tends to be increasingly resented the more highly these groups are organized . . . As the social services become more complex, more specialized and subject to a finer division of labour they become less intelligible to the lay councillor or public representative. A possible consequence is that, collectively, more power may come to reside in the hands of these interests. The question that needs to be asked of professional associations is whether they are prepared to assume greater social responsibilities to match their added knowledge and the power that accompanies it. Professional associations are not the only repositories of knowledge, but they are the repositories of a very special kind of knowledge; and the establishment of proper relations between them and the democratic State is, today, one of the urgent problems affecting the future of the social services.37 Besides their status insecurities, professionals may be unprepared to act in the social interest because of the blinkers imposed by their class background: In Britain and other countries, the professionals are largely recruited from the middle classes; professional workers come from homes and educational institutions where they have little contact with manual workers and people from different cultures. Thus, they bring to their work middle-class values in the processes of giving or withholding medical care, education, legal aid and welfare benefits. The model of the ideal pupil, student, patient and client is one with middle-class values and a middle-class tongue. This process, subtle and often unconscious, partly explains why in

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Britain, under universally available welfare services, the middle classes tend to receive better services and more opportunities for advancement. This is understandable; we all prefer the co-operative patient or client; motivated to achievement, anxious to learn, anxious to work.38 Finally, professionals may be out of touch with the social interest because of excessive specialisation, departmentalisation and hierarchisation of services. There is a danger that ‘separate interests, divided skills and special loyalties’, by provoking ‘an increasing fragmentation in responsibility for the treatment of the individual patient’, may lead to a shift in emphasis ‘from the person to some aspect of his disease’39 and to an ‘absence of critical self-examination arising within the hospital’.40 Against these negative forces must be set, however, the continued presence in the British Health Service of generalists as well as specialists, and also the sense of organic solidarity that results from interdependence among professionals and leads to demands for the social planning of medical services: Scientific advances have profoundly influenced the social and administrative organization of medical care. This is true of both ‘private’ and ‘public’ forms of organization. Conversely, the ways in which medical care services have been organized have influenced the application of science in medical practice. One effect of the interaction of these forces has been to make the doctor more dependent on the natural sciences for the practice of his art and, consequently, more dependent on society and his fellow doctors for the provision of an organized arrangement of social resources now recognized as essential for the application of modern medicine.41 Here there is a clear case of the division of labour operating with a self-transcending mechanism to promote in the last analysis greater cooperation, teamwork and pooling of effort (and less fragmentation of skills) than would otherwise have been the case. Science may pull the health services in opposite directions; but the resultant of the stresses is clearly in the direction of collective effort. Social planning must be complemented by education for citizenship so as to train the doctor to treat the patient as well as the disease. The sociology of the patient must no longer be neglected:

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The problem of the quality of medical care is in part an administrative problem; in part a problem of human relations in the hospital; in part a problem of bringing the hospital as a social institution back into society where it properly belongs and from which it has for too long been isolated. Today, all those who work in the hospital need to care much more about how and why the patient comes; what the person experiences as a patient, and what happens to the patient when he returns, as a person, to society.42 Doctors should be trained to see medicine as a social science. They should not lose sight of the fact that they are dealing with human beings as well as symptoms. Fourth, there are the politicians and the civil servants. They are accountable to the public and thus make decisions with an eye on the value-consensus. They emphasise considerations of social rather than individual utility. They ensure coordination, integration and balanced development on a national scale: ‘Only by planning can scarce administrative and professional staff be used to the best advantage.’43 Planning means cooperation, liaison, and the avoidance of wasteful duplication, but it ‘does not mean uniformity in every respect’.44 In Tanganyika, where Titmuss and his colleagues recommended an integrated health service responsible to central rather than local government, they took care to note that they did not intend ‘the centralisation of every decision. On the contrary, we would urge the need for devolution of responsibility within an overall plan as this is essential for flexibility.’45 The option of choosing a planned, coordinated and socially responsible health service is an important aspect of freedom of choice. Medicine, after all, is a community problem: ‘The traditional division between curative measures which benefited the individual and preventive measures which protected the community as a whole is becoming less distinct, if not obsolete.’46 Much that benefits the individual also benefits the community. Much that benefits the community also benefits the individual.

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13 The Failure of the Market III: Quantity

The quantity of welfare services available to the consumer in a system of free enterprise is deficient when compared with the situation prevailing in a Welfare State. There are in America, despite the prevalence of the market, a number of shortages and bottlenecks in the sphere of what in Britain has been politicised into social policy. Three examples from the world of medical care illustrate the logic that led Titmuss to conclude that American capitalism had not performed well in the field of quantity supplied. The first example relates to the growing shortage of doctors and nurses in America (as indeed of social workers, town-planners and teachers). So great is the shortage that it has had to be met in part by tapping supplies of foreign-trained professionals. America in this way saves the cost of training, but it also drains other countries and provides evidence of bad manpower planning. Titmuss’s argument loses some of its force, however, when he confesses that Britain too (despite its planned and coordinated Welfare State) is in the same position. Britain too is a net recipient of human skills (a form of reverse foreign aid) from the Third World. The second example, and possibly a less ambiguous one, concerns the supply of hospital beds. In America, despite the ‘advent of more profit-making hospitals as a source of capital gains’,1 the market mechanism evidently fails to stimulate adequate supply: ‘The number of hospital beds per 1,000 population dropped from 9.7 in 1948 to 9.2 in 1962. In England and Wales over the same period the number of staffed beds rose from 10.2 to 10.3.’2 Shortages are worse when one disaggregates. In terms of services, at the same time as there was overbuilding of small, inefficient but lucrative private hospitals in the United States, ‘the shortage of 230

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less expensive long-term facilities – for example, mental hospital beds – grew worse’.3 Profit-oriented private hospitals are reluctant to provide services which, however valuable socially, are none the less money-losers: ‘The corporations who operate these hospitals have decided not to treat “indigent” or “charity” patients and not to provide emergency, obstetrics or paediatric departments.’4 Also, in terms of geographical availability, ‘there has been little change over the past twenty years in the striking disparities in the state ratios of physicians to population in America’.5 There thus appears (despite the alleged existence of the fabled natural corrective of market forces) to have been a lack of balance in American medical services: ‘There is serious over-building of hospitals and gross duplication of expensive equipment in some areas, growing shortages in others, and a general trend towards greater maldistribution in important sectors of medical care.’6 Lack of coordination and planning means that it is sometimes impossible in America to get a bed in one hospital while a number of beds are empty in another. This is quite apart from the socially fundamental divergence between services in the suburbs and services in the inner city. Even in the suburbs there can be delays to see the doctor and hurried consultations when he finally arrives.7 Local shortages and maldistribution of services are endemic to a health system based on the principles of free enterprise. In Britain before the Second World War, Titmuss writes, there was a very uneven distribution of medical skill relative to social needs: ‘A few areas of the country and a small section of the people were abundantly served with medical and nursing skill, but in many places, especially the economically depressed areas, there were widespread shortages.’8 Consultants and specialists tended to concentrate in London, and even within London to settle in wealthier areas. Before 1939, there were ‘proportionately seven times as many general practitioners in Kensington as in South Shields’.9 Since 1948, however, the situation in Britain has radically changed: ‘“Unnatural” or governmental forces have undoubtedly brought about an improvement in the geographical distribution of doctors and medical resources in Britain since 1948.’10 In Britain, the introduction of the National Health Service has removed the financial incentive to the general practitioner of operating in a well-to-do area. It has encouraged equality of access through the planning of services. It has also minimised structural imbalances and local shortages by means of centralised coordination. The alternative would

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be the anarchy that results in a private system of independent and competitive units. The intricate proposals for a coordinated three-tier health service that Titmuss and his colleagues made to the Government of Tanganyika demonstrate just how much scope there can be for a system of integrated medical services. The Report called for ‘the creation of a chain of centres which will bring together curative and preventive services’.11 It recommended that, in order to spread the healthcare network reasonably evenly throughout the population, the country be divided into 40 ‘health areas’. Each area was to consist of 25 health clinics, five health centres, and (except in more remote areas) one hospital. The respective functions were to be as follows. The health clinics were to perform simple curative and preventive tasks on a local basis. They were to treat common diseases and minor ailments, perform antenatal examinations, detect the symptoms of malnutrition, educate mothers in the elements of infant and child health, teach the local population about hygiene, cleanliness in the preparation of food, the need for a balanced diet. So important is the educative function of the clinic that even the clinic building itself ‘should be maintained at a high standard of hygiene as an example to the local community’.12 Medical personnel are scarce in Africa. Hence the clinics were to be staffed not by doctors but by trained medical auxiliaries. By carrying preventive services into the community and the home, they help to reduce the future demand for curative medicine. Again, by vetting cases locally and referring only those which they cannot themselves treat with simple drugs and equipment, they help to ration the scarce skills of the highly qualified. This is a more economical use of resources than for the sick to queue up at out-patient clinics. It prevents the hospitals from being swamped with improper demands which cannot but waste their time. The health clinics are important as information-gathering organs: ‘The staff of the health unit should know the habits of the local people and observe and report any significant changes in the pattern of disease.’13 They are also important in the formulation of policy, since the clinics are closely integrated both with local government and the local population. At the governmental level, the clinics often work in conjunction with other local services (such as sanitary and sewerage infrastructure, town-planning and pest-control authorities, agricultural schools) to satisfy local needs. Services such

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as good housing or the eradication of malaria are essential to a healthy environment and must link up with the work of the clinics that treat. Again, and because the clinics have an on-the-spot presence, they act as a catalyst for ‘what the people themselves can do, individually and through collective programmes of self-help and community development, towards the improvement of health at the level of the local community’.14 Medicine is a community problem. A developing health programme ought to enlist the support of local people who are the stakeholders in self-improvement. Above the local health clinics in the hierarchy were to be the health centres. Each centre was to provide continuous education and supervision for the medical auxiliaries staffing each of the five clinics in its area. The director of each centre was to visit each clinic at least once a fortnight, both for preventive purposes (say, to help structure immunisation and family-planning campaigns) and in order to diagnose and treat difficult cases (an activity partly curative in function, but also partly educative in so far as it helps to train medical aides and in that way to raise the standard of their future work). Difficult cases were to be referred to the centres, which would have some beds available for them. The general rule was to be this: The health centres, with their satellite health clinics, and their links with area hospitals, should further their aim to provide good medical care by becoming local powerhouses of health education and preventive medicine. We see them acting as demonstration and group teaching centres in healthier living; consulting, advising and assisting local leaders and groups, health workers and midwives in how to work with others in raising levels of living.15 Still higher in the hierarchy were to be the area hospitals. They were to deal with more difficult cases that were referred to them from below, and also to supervise the work of the health centres in their area. At the apex of the hierarchy were to be the category ‘A’ hospitals (no more than three in the whole country). These were to be large (500 beds or more). Each would not only serve as local general hospital for its own area but would also act as the reference hospital for a number of health areas. Each was to have a staff of qualified consultant specialists, who would regularly visit smaller hospitals to teach and advise: in an emergency they could even be called

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upon to give guidance by radio to hospitals in isolated districts. In addition, each category ‘A’ hospital was to set standards for other hospitals, partly by acting as a postgraduate training centre, partly by accepting medical officers from other hospitals for short periods to bring them up to date with new developments and advances in their field. The essence of the recommendations is the need for links and networks, for continuous education and a community base. Titmuss believed that the precondition for all of these proposals was a state system of medicine within which limited resources were allocated on a national basis according to a plan formulated by the central government. It is interesting that, although Titmuss obviously had no great love for private hospitals, he did not call for the nationalisation of voluntary agencies or regard it as essential that they be integrated into the system.

The first example was staff and the second was beds. The third is blood. Transfusion is yet another service that is inadequate and deficient in the American private enterprise system of medical care. The demand for blood in America is increasing rapidly, partly because of general sociological factors, partly as a result of advances in medical knowledge and techniques. There is, for example, a higher incidence of road and industrial accidents, more urban violence, a rising percentage of the population over 65 and in need of proportionately more surgery. Then, too, there are more haemophiliacs seeking the blood they need; more ‘poor-risk patients’ being accepted for surgical treatment; more open-heart and major cancer operations; more organ transplants. The supply of blood in America is, however, not keeping pace with these new departures. As a result, chronic shortages of fresh blood now exist in most places. In New York, for example, ‘operations are postponed daily’ because of the ‘acute and chronic shortage of blood’.16 Elective operations are often scheduled with an eye to its availability. The problem in America is that the crude utilitarianism of the private market has failed to establish a satisfactory equilibrium. Blood appears to have a low price elasticity of supply, since substantial monetary incentives (to say nothing of trading stamps, tickets to baseball games, or discounts on prison sentences) are evidently inadequate to attract sufficient donors. Moreover, there are, here as elsewhere in the market, failures of coordination such that blood

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might be expiring in one hospital (and thus being wasted by not being used within its 21-day life-span) while at the same time nonavailability of blood could be causing an operation to be postponed in a neighbouring institution.17 Any shortage of blood is an infringement of the patient’s freedom of choice. It reduces his freedom to have an essential operation, and possibly even to go on living. Market forces curtail freedom in the area of blood. State intervention extends it. In Britain, blood is a valuable commodity but, because of the system of voluntary donorship, a commodity without price. Yet, unlike the situation in America, in Britain ‘there is no shortage of blood. It is freely donated by the community for the community. It is a free gift from the healthy to the sick irrespective of income, class, ethnic group, religion, private patient or public patient. Since the National Health Service was established the quantity of blood issued to hospitals has risen by 265 per cent.’18 In the same period (1948–67) the total population of England and Wales rose by 12 per cent.19 Moreover, ‘the number of blood donations per 100 potential donors rose steadily from 1.8 in 1948 to 6.0 in 1968’.20 The increase has been orderly and sustained, and an increased supply has at all times been forthcoming to meet an increased demand. Clearly, it is economically inefficient to treat human blood as a consumer good to be purchased from commercial sellers. Other affluent and mobile societies such as America, Japan, Sweden and Russia do so. Conspicuous shortages have been the result. It makes sense, Titmuss argued, to rely on altruism rather than sale, and to recognise that blood is not just another economic good. In Britain, because of the system of voluntary donation and the suppression of the cash nexus, the response rate is satisfactory, the supply predictable. Altruism is capable of doing the job. Private enterprise demonstrably is not. Not only is more blood forthcoming in Britain than in America, but existing stocks are more effectively utilised. The 21-day lifespan of blood, combined with the fact that it is unhealthy for donors to give blood too often, suggests not only the need for a wider network of donors but also that efficient use should be made of limited supplies. This in Britain is ensured by central coordination of blood supplies. Scarcity of blood is a microsociological as well as a macrosociological phenomenon. Here again the British system is seen to be superior. A patient may count on receiving blood in Britain who in America would not even have been able to afford treatment. An American

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haemophiliac, who may require a vast quantity of blood for as simple an operation as the removal of a tooth, is a bad risk and finds it difficult to arrange private medical insurance, at least at an affordable price. A British haemophiliac, on the other hand, receives blood as a free gift from strangers and is not separated from it by a payment barrier which may appear insuperable (as when there is more than one haemophiliac in the family). A British haemophiliac, as Titmuss so eloquently puts it, ‘would not wish to emigrate’.21 Needs, when met and not ignored, increase pressure on budgets and resources. Importantly, they may also increase the sum of social felicity. The liberal theory of supply and demand prices need satisfaction on the basis of the willingness to pay. Titmuss, concerned about distributional inequalities and aware that not all need is matched by effective demand, invokes the stricter test of consensus. The quantity supplied may be said to be sub-optimal even where the excess demand is zero precisely because market supply might not correspond to the goals and targets that public opinion holds to be the meta-ends that go beyond exchange. Consider, for example, how property speculation has forced land values and rentals to prohibitive heights: ‘Private enterprise is only building about 1,000 new dwellings a year in the county of London . . . and most of these are luxury flats for the rich.’22 In such a case, quantity supplied is not only deficient but patently out of line with the self-perceived needs of the society as a whole. There is, Titmuss reasoned, much to be said for dirigisme if it can at the very least hold at bay ‘the predatory vulgarities of land speculators and property developers’.23 Another example of undersupply is the residual slums which tend even in Britain to be underdoctored24 despite the fact that they have an acute need for high-quality professionals to integrate the poor and the non-white with the rest of their fellow citizens. Here reliance on the invisible hand of the market mechanism would make the situation worse, not better. What is needed is planning with a view to the satisfaction of social as well as individual needs. Only through planning of resource allocation can the quantity society thinks ought to be available be put at the disposal of those whom society feels ought to be empowered to enjoy it.

14 The Failure of the Market IV: Price

America in the 1950s and 1960s spent a higher percentage of its gross national product on medical care than did Britain. This fact does not, however, demonstrate that the quality of service in America was better, or that the quantity supplied was greater. It might simply reflect rising cost to the consumer: ‘Since 1958 it has risen much more than in Britain . . . By far the steepest rise has been registered by the price of hospital rooms and group hospital insurance premiums. These are now rising at the rate of over 7 per cent per year, or twice as fast as the national income.’1 American medicine is already expensive. It is experiencing rapid price inflation in excess of the general rise in the cost-of-living index. The reasons, Titmuss indicated, were not chiefly to be sought on the side of demand (the argument that medical care is a luxury consumer durable with a high income elasticity) but rather on the side of supply. Five examples will help to make his logic clear.

First, there is a lack of coordination among private hospitals in the United States, and many suffer as a result from underutilisation of plant: ‘One part of the price of non-planning – a 26 per cent average non-occupancy rate in short-term general hospital beds in 1957 – cost American consumers $3.5 billion in idle investment and $625 million in operating costs.’2 The duplication of expensive and sophisticated equipment in these hospitals suggests wasteful maldistribution of resources. There is also the point that, because of the ‘technical rationale for large units’,3 small, profit-making hospitals experience diseconomies of scale which are ultimately translated into higher prices charged to the consumer and into slower national growth rates caused by misallocation and underperformance. 237

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Second, there is the administrative waste that results from parallel bureaucracies in the private sector. In the economic pluralism of the American system, it is the consumer who pays for these multiplied inefficiencies of organisation. In the case of private provision of blood, the consumer must pay for all the waste in the system, including ‘an immense and swollen bureaucracy required to administer a complex banking system of credits, deposits, charges, transfers and so forth’.4 The same is true of medical insurance: ‘The administrative and commission costs of insurance companies for individual policies rose from 42 per cent in 1948 to 52 per cent in 1958. The consumer now gets less than half his dollar back in medical care.’5 British experience confirms the inefficiency of private provision in the field of insurance: The administrative costs of private Workmen’s Compensation Insurance were of the order of 30 to 40 per cent of the premiums collected. Such figures can now be compared with the administrative costs of the Department of Health and Social Security in administering the present system of National Insurance against Industrial Injuries and Diseases. These costs are in the neighbourhood of 5 to 10 per cent. The private market was many times more costly in terms of administrative efficiency.6 Bureaucracy to most people suggests the State. To Titmuss, however, as to Max Weber, the term meant the hierarchical structure of any large organisation, public or private. Titmuss went further than Weber and argued that, given that bureaucracies are a fact of modern life, at least state bureaucracies have the edge in respect of cost-efficiency. There is more coordination in the state sector, less duplication of administrative and computer overheads, no selling and advertising costs. There is substantial saving of resources due simply to the fact that the doctor in Britain does not need to inquire into the financial means of each patient, to send in bills, to file suits for non-payment, to absorb bad debts. Titmuss deplored the waste involved in private-sector bureaucracies. The following economystic jeremiad picks up the passion: ‘How much longer are we to be burdened with the heavy and wasteful administrative costs (to say nothing of the misuse of computer time) of the chaos of something like 60,000 private pension schemes?’7

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Third, there is the financial cost to the consumer of the breakdown in the doctor–patient relationship. In America, doctors take out expensive insurance against possible litigation. They attempt to pass the high cost of the premiums on to the patient. Moreover, insurance companies protect themselves by obliging doctors to perform supplementary tests and to fit in medically unneeded consultations. Such ‘defensive medical practice’ in the long run must put up the cost of care. Again, the doctor may waste resources on unnecessary treatment due to the lure of financial return; and may concentrate on curative medicine (in which he has a personal interest) to the detriment of preventive (in which he does not). The incidence of hepatitis too imposes a financial cost on the sufferer and his family and gives him a sensation of misplaced trust. Indeed, once the patient loses confidence in his doctor and comes to see that the parties are linked by a profit-oriented commodity transaction rather than a disinterested professional ethic, there is likely to be more hostility, more litigation, and hence a further financial cost.

Fourth, there is the high cost of blood to recipients who have to purchase it for money (those, for example, who do not repay in blood under the terms of blood-replacement schemes). The cost of blood supplied in the United States is 5 to 15 times higher than in Britain.8 Partly this is because American blood is regarded as a consumer good to be bought and sold at whatever price the donors and the blood banks can negotiate for themselves. By offering a price, private enterprise drives away the public-spirited. That leaves the mercenary donors; and they must be paid. Partly too the high cost of blood in America reflects administrative waste occasioned by lack of coordination between a plurality of bureaucracies. About 15 to 30 per cent of all blood collected in the United States is lost through outdating (due to its perishability at the end of 21 days9), a multi-million-dollar annual loss but one which is to be expected in a system where in 1966–68 there were some 9000 individual blood banks involved in drawing blood.10 Central coordination in Britain both allows for effective mobilisation of existing supplies and ensures full employment of facilities and administrative staff. It also allows for the planning of the shortterm demand curve. In England and Wales, only about 2 per cent of blood collected is wasted through inefficiency. In America the figure is possibly ten times as high.11

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Then, too, blood in America is expensive because of wasteful practices in the hospitals. Blood is squandered on defensive medicine; on medically unjustified surgery (such as an unnecessary appendectomy); and on supplementary treatment where the patient is cross-infected with hepatitis in the course of a transfusion. Bad blood is a costly externality: the patient must then pay for further professional services, for expensive days in hospital, and for still more blood. Blood is often the object of deliberate overordering by physicians (who prefer waste to shortage) and of hoarding by hospitals (which, believing that ‘blood loaned is gone forever’,12 prefer waste to sharing). Finally, blood in America is expensive because of international competition to obtain a scarce commodity. Blood and plasma are sold to the highest bidder. There is substantial export from the United States to other countries (such as Sweden and Japan) where social growth (as approximated by the index of voluntary donorship) has lagged behind economic growth and a blood shortage has emerged as a result. Paradoxically, the high cost of blood makes America seem a richer country. Waste boosts American GNP figures, since stocks of blood are stocks like any other and since commercialisation of transfusion systems converts an unpaid into a paid activity. Even the wasted services of the hospital used in treating induced cases of hepatitis are included in the GNP. What is excluded is the social cost. Yet the unquantifiable effects on family life of, say, permanent dependency on the State because of a transfusion involving polluted blood must have a significant social value, despite the fact that they have no market price.

Fifth, there is in the United States a ‘trend from domiciliary to hospital care’,13 partly due to the declining importance of community medicine and the local GP. In America, private, specialised medical care has ‘built-in professional and financial preferences for institutional care’.14 The patient is likely to be sent directly to a hospital, geared more often than not to short-stay patients and a high turnover. Needless to say, such treatment is expensive. Here as elsewhere, the privately produced article is inferior. It cannot stand up to the competition of a socially provided service.

15 Part Four: Evaluations and Extensions

Mainstream economics is concerned with the efficient allocation of scarce goods and services where a rational choice must be made between a number of competing alternatives. Its methodology is individualist, it postulates the non est disputandum of ends, and it assumes the whole to be equal to the sum of the parts. Liberal and utilitarian in its outlook, it assigns a normative as well as a positive value to the way in which the self-interested household or firm votes with its budget in the unrestricted marketplace. Sociological economics, on the other hand, is anthropocentric rather than reiocentric in approach. It regards the production, consumption, distribution and exchange of goods and services as a bundle of social facts, at once a part of a wider matrix of socially situated phenomena and a mystery which social causes and their effects alone can be in a position to resolve. Sociological economics recognises the organic interdependence of banding and bonding as a reality sui generis. It stresses that ends are often prescribed by social mores rather than representing the unpatterned accidents of factored-down choice. It accepts that valued goods and services exist which have to be supplied and demanded collectively if they are to be demanded and supplied at all. Sociological economics acknowledges that the group as a whole must frequently make a decision as a crew on the direction in which the team members wish to row. It consequently puts particular emphasis on voting patterns, political parties and programmatic ideologies. Richard Titmuss was strongly attracted to the cross-disciplinary synthesis of sociological economics. In his assertion that economic growth and social growth should move like complements in step, in his demonstration that economic performance like social policy 241

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could be assessed using the benchmark of consensus, Titmuss showed that he wanted the wealth of nations, like welfare itself, to become a sub-topic in the wider theory of society. Just as strong as his attraction to the human-centred model of resource allocation was, however, the revulsion he felt towards the textbook mainstream which put money before morals and selfishness above cohesion. Titmuss knew that his task was a dual one, pulling down as well as building up. The problem, as Pinker states, is that he did not devote equal time to each of his twin objectives: Much of Titmuss’ published work can be read as a continuous indictment of the values of private enterprise and the profit motive. It is therefore easier for us to form an impression of the kind of economic system which he would have eschewed than to identify the one which he preferred.1 Strongly attracted as he was to a new economics of intermingling and community, what is explicit in Titmuss’s published work is more an attack on an intolerable world-view than a blueprint for the superior paradigm that was to be constructed in its place. Pinker has no objection to a more sociological economics which embeds the market in its context. What he finds a cause for concern is the fact that Titmuss, attacking the textbook mainstream, seems to be adopting a ‘holier-than-thou attitude towards the values and imperatives of the economic market’2 without also recognising the great good that free enterprise has done in bringing about full employment, promoting economic growth and integrating disadvantaged minorities who, thanks to affluence, have no need to exercise their welfare rights. Pinker at the positive level sees no reason why economics should not be made more sociologically informed. What he finds an unacceptable extension of the more sociological paradigm is the normative inference that profit-seeking is always and everywhere a disreputable activity: ‘However much more highly we may rate the values of the social market as against those of the economic market, nevertheless the capacity of the social market is contingent on the wealth-producing capacity of the economic market.’ 3 Titmuss, Pinker is suggesting, would have done well to have spelled out his alternative to exchange before he turned so aggressively on the golden goose that had made possible the redistribution: ‘The first condition for a gift relationship is the existence of a gift worth giving.’4

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Titmuss was reluctant to admit that the economic market could be the first condition of the gifts community. The implications of his negative stance will be explored in the four sections – headed Scarcity, Choice, Growth and Pattern Maintenance – of the present chapter.

(a) Scarcity Titmuss recognised, in the case of Tanganyika at least, that where resources are not infinitely available, there is a need for social policy to be realistic: ‘The more limited the total resources available, the greater the need to husband those resources carefully; to order priorities in the right balance, and to set clear objectives for the future.’5 So aware was Titmuss of the extreme deficiency of resources in Africa that he joined with his colleagues in opposing the universalisation of state-provided medical insurance. Health cover should certainly be introduced; but only in areas where medical services were already well developed. The reason for the caution was this: We expect that the introduction of such a scheme, even if contributions were limited to employers, would result in heavier demands for medical attention. It would not be right, in our view, to introduce a scheme and to lead certain sections of the population to expect to claim better medical care if the resources and staff to meet such demands are not available. In general, then, the development of a health insurance scheme should march in step with area improvements in medical resources.6 Otherwise, standards of service would fall; and ‘this should not be allowed to happen’.7 Because of the existence in Africa of a severe supply-side constraint, Titmuss recognised the need for the gatekeeper of price in order to ration away excess wants that could not be met. Health charges were the key to quality consultations in the proposals that he and his associates made in Tanganyika. There the problem was simply this: ‘The more cases any medical worker is expected to see and treat in a day, the less time can be given to each and the less the value of the service given.’8 In order to defend the value of each consultation, some means had to be found of limiting the quantity demanded; and the recommendation that was made was for fees. The charges were to be moderate: if they were too high,

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they would frighten away poorer patients (who were probably the most in need of attention). There were to be exemptions: thus antenatal care was to be free and fees were to be waived for indigents at the discretion of staff (a full means test being impossible in an underrecorded economy). With these exceptions, sick people were to be asked for co-payment. Titmuss was able to recommend the price deterrent of user charges in the absolute scarcity of East African underdevelopment. The National Health, however, was to remain resolutely free on demand. In advancing what is intendedly an asymmetrical argument, Titmuss seems to have been saying that nations evolve out of excesses and deductibles once they grow into the stage of reasonable affluence. A different perspective would be that richer societies are insatiable consumers of healthcare and education; that the demand for highincome welfare will expand at least as rapidly as supply; and that the Tanganyika scenario is every day coming closer to being the British present. Harnessing the negative correlation between changes in price and changes in quantity might in the circumstances be a useful way of rationing scarce supplies where not all clients can have what they want. Titmuss knew that the introduction of charges for dentures and spectacles in 1951, and of more extended charges in 1952, had ‘had some effect in reducing demand’.9 Even in the National Health, it would appear, a Tanganyika response had demonstrably reduced the pressure. A similar defence could be made for consultation fees in health and course fees in education. Allowance made for the pain cost of surgery and the opportunity cost of training, it is a matter of simple logic that more of a free good will be demanded than would be the case if the benefit were to be matched by a personal sacrifice. Self-inflicted illness wastes the scarce resource of curative care: easy access to doctoring provides no incentive to smoking less and jogging more. Vocationally targeted degrees inflate the pay-off to human capital: graduates’ surplus is only partially clawed back through progressive taxation. Charges that reduce the pressure by pushing out the poor are by consensus bad charges. Charges that stimulate self-initiated prevention and internalise the middle-class rent may not, however, be wholly out of keeping with Titmuss’s view of the self-reliant citizen who imposes no burden but that which is fair.

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Titmuss’s system is one of rationing by need and by right. Where supply is limited, however, such a system often degenerates into the makeshifts of second-best. Titmuss hardly mentions long waiting times, overworked doctors, overloaded social workers, lightning consultations, ad hoc means tests, all of which are both indicators of scarcity and de facto allocative mechanisms. He seems not to anticipate the frustration, the disappointment and the cynicism which threaten the credibility of the welfare promise in a resource-constrained environment where not all demands can be adequately met. Titmuss takes for granted that allocation by professional will be acceptable where allocation by price is not. A different assessment would be that the criteria and priorities of a self-regulating élite undoubtedly manage scarcity but only do so through an authoritarianism that stigmatises in a manner that Titmuss never envisaged. Should the experts decide, for example, that computer training for the young should enjoy a superior ranking to kidney transplants for the old, the geriatric (who on the grounds of economics are condemned to simple maintenance without major repair) may well see themselves as unwelcome pariahs and rejected has-beens. Allocation by expert need not be more humane than allocation pre-paid through private insurance. Nor will it always follow rather than lead the public’s values and preferences. Titmuss underestimated the shortcomings in rationing by need and by right. Being realistic, he had to do so – since the alternative would have been charges, and charges to him looked mean. Titmuss, writing of welfare goods, was attempting to apply the one person, one vote of the political democracy, to exclude the differential incomes, differential votes of the economic market. Charges would be both unequal and inequitable, sometimes prohibitive but always regressive. The only way that those least able to pay could be cushioned against co-payment would be through the personal means test that Titmuss so much opposed. Over-utilisation, he probably reasoned, is morally superior to under-utilisation. Most of all will it be so where stigma can be avoided through the avoidance of the means test that would be necessary if the poor were not simply to be crowded out. Titmuss was in many respects a man who, like Nye Bevan, had stopped the clock in 1948. Bottlenecks would be relieved by larger departmental budgets. Spending would level off once the backlog of neglect had been made good. The taxpayer and not the consumer was the proper source of revenues. There is in all of this no

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technological revolution in expensive healthcare, no widening in social reference groups, no upgrading of personal expectations such as leads to permanent pressure for an improvement in comfort and amenity. Scarcity had ended when the National Health came in. An overoptimistic view even on that historic first of July, laser surgery and the CAT scan have put scarcity back on the agenda again. That is why it is essential for the Titmuss model to be extended in order to say what should be done when demand, self-perceived, consistently rises at a faster rate than tax-funded supply.

(b) Choice Titmuss expected welfare to make a valuable contribution to consumption and empowerment: ‘Basically, it is a question of freedom – of the liberty of the subject which cannot be disassociated from material conditions.’10 He also believed that it should do so in such a way as to tailor the product to the specific needs of each unique one-off: ‘Social services are those collectively organised activities, public and voluntary, which aim to provide the individual, as an individual, with the precise form of assistance he needs, and which must therefore be adjusted to meet the circumstances of each “case”.’11 As an individual meant top–down professionalism on the model of the wise dentist who fills the teeth. As an individual also meant bottom–up valuation and revealed personal preference. Titmuss (as he had done with the Christians on ‘sin’ and the Marxians on the ‘dialectic of hedonism’, the ‘blood proletariat’) flirted with the linguistic conventions – the ‘freedom’, the ‘efficiency’, the ‘Paretian optimum’, the ‘productivity’ – of the pro-market economists. He was in a strong position to do so. Their friend as well as their enemy, what he shared with the utilitarians and the liberals was an Englishman’s commitment to respect for persons – and to choice. The textbook market prices goods and services by what the traffic will bear. It measures changes in needs in terms of changes in profits. Competition will often be imperfect and redistributions of purchasing power generate different kaleidoscopes of equilibration. The textbook economics is open to telling criticisms in respect of oligopolisation and starting-point endowments. Taken on its own terms, however, it is an attractive partner in the democratic enterprise. It enables the individual to register orderings and to signal intensities. It is in that way a useful source of information on what

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bottom–up actually desires, since it supplies an impersonal record of the choices that people actually have made. Titmuss knew that he had to prove that information collected in the welfare sector was at least as robust as the purchases tracked in the market. In the end, however, he did not so much prove that good outcomes would result from good intentions as simply restate his confidence in human nature when given the privilege to serve. The consequence is an unwarranted optimism as to the factoreddown state of mind of the mature student thinking through her second chance or the low-income old person with a list of services that would enable him to remain in his own home. Titmuss never explains how a society is in practice to determine the optimal rather than the minimal provision of a free good; or how information is to be collected from the parents of schoolchildren or the patients at a clinic about the choices that each as an individual would most like to make. The possibility in the Titmuss model is real that, data being scarce and imprecise, the welfare options selected will reflect the view from above of politicians, professionals and administrators rather than the view from below of the faceless mass of takers, inarticulate and passive. There are often a multitude of ways to satisfy the same human needs or wants. The collectivity has no way of knowing what Henry Dubb actually desires unless it asks him for his rankings and his cardinalities. The textbook market can be modelled as if conducting the requisite process of consultation. Democratic welfare in the sense of Titmuss remains to be so modelled as well.

However sensitive the welfare services may be expected to be, still the two-sector model must introduce problematic non-comparabilities into the information flows that are observed. Two commodities in the market sector can be compared in terms of the money the consumer is just willing to sacrifice in order to secure an endowment of each. Two commodities in the welfare sector cannot be compared in the same way: the marginal sacrifice involved in a free-on-demand choice has no paid-out value. Most confusing of all is the comparison of two commodities where one is an exchange-sector purchase and the other a welfare-sector gift. In the mixed society the consumer has no way of making a crosssector evaluation: he cannot price a visit to the doctor to complain of a hangover in the Walrasian numéraire of nine pints of best bitter

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foregone. The information encoded in revealed preference manifests a skewness induced by the fact that the market good is deterrently dear while the welfare alternative is temptingly free: the popularity of the National Health relative to private insurance may be explicable in terms of money-minded patients who see no reason to pay twice. The consumer, moreover, cannot, in the mixed society, make a meaningful adjustment at the margin. He cannot decide, for example, to spend £100 more on a colour television and £100 less on a diagnostic test, but is, in the welfare sector, disproportionately the creature of decisions made by others. Not only does this reduce the liberty of the individual to spend his own money as he sees fit (a point the advocates of market capitalism have not been slow to stress); it also makes it more difficult to put an interpretation on the data thrown up by the bi-sectoral experience. It is virtually impossible for policy-makers to make direct comparisons of means and ends between the market and the welfare sectors: the success indicators are too different. Titmuss makes the implicit decision not to incorporate into his theory of efficiency within welfare those forms of the utilitarian calculus (such as cost–benefit analysis or public-sector investment criteria) that could serve as a common denominator. Even in Income Distribution and Social Change he avoids the use of an intertemporal rate of discount, presumably because the interest rate is market-tainted and irrelevant in the area of social policy. Irrelevant it may be, but its absence does leave an information gap in his model that can only be narrowed through the development of reliable intersectoral indicators. The price mechanism has a general as well as a partial equilibrium function. Ideally optimal (in the sense of the Walrasian tâtonnement) or merely best-attainable (in the sense of the Hayekian discovery process), the market is held by the libertarian economists to ensure the coordination of a large number of discrete decisions. Pricing reconciles the data. The mixed society merely juxtaposes the imponderables. Titmuss does not say how the two sectors are to be made integrated partners in a single economy. Nor does he explain how to distinguish a bad mix from a good mix – let alone from a mix which feels adequate but is still not up to the limits of potential. Implicit may be some form of state planning. Titmuss had lived through the Labour Party debates of the 1930s and 1940s and had

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been exposed both to Fabian leaderliness and to Fabian scientism. George Brown’s National Plan in 1965 must in the circumstances have had the look to him of an old friend coming home: ‘Now that the Government has begun to lay a sounder basis for a higher rate of growth in the future after inheriting a decade or more of incompetence and dereliction it is, I think, rather more than less likely that our economic targets will be broadly attained.’12 Surprisingly, perhaps, given the thrust of his multidisciplinary aspirations, Titmuss does not explore the precise form that welfare coordination within a wider plan ought in his view to take. He was able for that reason to side-step the possibility of a trade-off between manpower and welfare planning on the one hand, and freedom of individual choice on the other. Yet there can in practice be a real conflict between one person’s desire to study metaphysics and his society’s general will to equip itself with skilled engineers. In such a case the would-be philosopher might deeply resent the imposition of a numerus clausus by the State. He might even offer to pay a higher price for the right to study the unproductive and self-indulgent subject which maximises the subjective utility that he quantifies through his proposal. He will seek in vain to actualise his choice in an educational system founded on social plan rather than individual preference. Titmuss writes that ‘all social services are allocative systems and ration demand and supply’.13 Indeed they are; and that will be why the philosopher expected to train as an engineer will not be free from a certain measure of bitterness and regret. Titmuss acknowledged that hospitals even in Britain had not always appreciated the extent to which ‘courtesy and sociability have a therapeutic value’.14 He attributed this intermittent neglect of the human touch to the fragmentation of service, the division of professional labour and the hierarchical structure of a closed institution. Optimistic as always, he was confident that people, not cases, would ultimately emerge the victor if only the non-pecuniary path were to be selected by a nation that values choice. Wilding’s comment is that there is rose-tinted wishful thinking in Titmuss’s picture of a world that transcends the sale: This optimism came out in his belief that the accountability of the public sector means that it is more likely to be responsive to consumer pressure than the private sector. Sadly . . . that social accountability has too often remained a polite fiction. Those

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responsible for public welfare have not shown a desire to develop flexible and user-sensitive services.15 If Wilding is correct, the failure not just to collect but to make good use of information about the client as an individual is more than merely an intermittent shortcoming. Titmuss explained the possibility of neglect with reference to organisational rigidities. Others would predict the inevitability of neglect from the simple fact of monopoly provision. Where suppliers compete for sovereign consumers, the individual has in his own feet the power to vote against rudeness: he can apply economic sanctions by taking his business to another shop. Because welfare services do not compete for sovereign consumers, the client has no alternative to the passivity of the taker who does not choose. The consequence is a deficiency in the supply of flexible and user-sensitive services, accompanied by a humiliating loss in self-respect and the freedom to be heard. Should the real threat to choice come not from excessive specialisation but from inadequate competition, alternatives to the monolithic bureaucracy must be explored such as would be favourable to search and initiative. One such alternative would be to break the link between finance and provision through a system of welfare vouchers. Vouchers could be graduated in line with household income: this would ensure supplementary earmarking to the advantage of the less well-off. They could be augmented out of the family budget: top-ups divert new funding into welfare which in a free-on-demand system might have gone on luxuries. They could be encashable at approved private as well as approved public outlets: fungibility blurs the distinction between Eton and the local comprehensive while forcing both sectors, aware that the customer is shopping around, to deliver value for money in order to earn life for their staff. Vouchers are conducive to pluralism and diversity in areas such as education (where some parents want academic standards and discipline while others prefer sports and self-development) and healthcare (since ‘fringe’ and ‘complementary’ therapies, singlesex wards, uneconomic neighbourhood hospitals are all brought within the choice-set of the unique individual with economic power at his fingertips). Vouchers mean an end to coerced conformity and stimulate tolerance of multiple lifestyles. They also make the receipt of welfare less stigmatising in itself. Automatic state income supplementation is in such a system both universal (all receive some

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vouchers in identical sealed envelopes) and impersonal (not at the discretion of the powerful office-holder, not on the petition of the timid beneficiary). Welfare vouchers are by no means incompatible with socialist values. They are paid for through progressive taxation. They level life chances where the poor get more. They integrate schools. They mix communities. Housing vouchers replace the ghettos of the council estate with rent subsidies paid on a sliding scale to households. Poorer families are in that way empowered to settle in neighbourhoods that become as balanced a cross-section of the British population as the maternity ward of a large state hospital. The catchment of the local comprehensive is made more comprehensive as a result. The less privileged are spared the stigma of the neighbourhood apart when what they really want is a semi-detached in Ambridge like the rest of their national family. Vouchers, one reflects, may be the missing element in the community-building allocation of housing that socialists have long sought and that even Titmuss did not really find. Voucher finance can clearly be made an extension of welfarist values. Whether Titmuss himself would have been receptive to such an extension is, however, a good deal less likely. Asymmetric information makes the client vulnerable to the conflict of interest of the freelance surgeon or other paid professional. Means-testing is a source of stigma even if it does prevent the scarce butter of welfare from being spread too thinly. A multiple and differentiated service is a threat to the common identity that is the very essence of integration-furtherance through universalist experience. The relief of chronic distress by the compassionate social worker does not lend itself to the fees and prices of welfare-merchanting in line with subjective valuation. Vouchers impose a heavy administrative burden. Welfare without vouchers makes possible an economy in the administrative overhead. Internal markets invite corner-cutting and open the door to reprivatisation. Reprivatisation imposes a twotier system and is a source of economic waste. Titmuss would probably have rejected as mean-minded and unwelcoming any suggestion that the more affluent should de facto pay differential school fees and prescription charges. He would probably have dismissed as a threat to common citizenship any proposal for variety above assimilation that paid for ethnic minorities to withdraw into separate educational facilities. He would probably have condemned as narrowly consumerist any model of money

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following the client which failed to assign an active role to the social consensus in support of spillover externalities and collective needs. Welfare vouchers can be made compatible with a range of socialist theories. Whether the Titmuss model can be extended to become a market socialism of shopping and enterprise is, however, less likely. Titmuss underestimates the contribution that competition can make to social welfare. He also provides a selective and often an exaggerated account of the way in which private welfare has let the nation down. In one place he argues that the American purchaser of medical insurance gets back less than half of his dollar in the form of care: only later does he add that these high overheads relate exclusively to individual plans, and that the benefit-to-contribution ratio for group policies can reach 90 per cent.16 Elsewhere he compares the efficiency of the private-sector insurance industry in the 1930s with the efficiency of public-sector social security in the 1960s: he does not point out that the gap of 30 years almost certainly made the data non-comparable.17 Titmuss is attracted by worst-case illustrations such as Skid Row blood banks, non-transferable pension rights, unneeded appendectomies and drugs, doctors with investments in hospitals and clinics, fee-splitting when an unsuspecting patient is referred on to a confederate. Highlighting the horror stories in the private sector, he passes over in silence their Welfare State counterparts – the exhausted practitioner who instinctively hands out tranquillisers, the university teacher with a major consultancy interest, the confidential files that provide a home for malice and innuendo. Titmuss’s choice of examples is not an even-handed one. They make the private sector seem worse than it is, the state sector appear more of a family friend. The horror stories are particularly horrific by virtue of the fact that the anecdotes are logged gross, not net. Unusually for an interventionist, Titmuss says little about the use of regulatory legislation to curb the worst excesses of unbridled gain-seeking. Pierson is more sensitive to state power and state management as a democratic compromise which knocks the rough edges off the buccaneers while retaining the dynamic of disciplined enterprise: In this way, it was possible for social democrats to represent formal ownership of the economy (and the traditional strategy of socialisation/nationalisation) as (largely) irrelevant. Economic

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control could be exercised through the manipulation of major economic variables in the hands of the government. The owners of capital could be induced to act in ways which would promote the interests of social democracy’s wide constituency.18 The law of the land comes in. The law of the jungle goes out. Economic welfare channels market capitalism into social service. It does so without collective ownership or monopoly provision. Titmuss could have called for laws that make private pensions portable and protect survivors’ rights. He could have insisted that the approach to a fee-for-service specialist should be funnelled through a primary-care doctor and validated by a cost-conscious insurance company. He could have demanded that commercial blood banks assume legal responsibility for an inadequately tested product subsequently found to be defective. Commercial banks which trade in money are licensed and screened to prevent anti-social sharp practices. There is no reason why commercial banks which trade in blood should not be subjected to a similar process of supervision and direction in order to ensure that the consumer’s interest is not sacrificed to gain.

(c) Growth Titmuss was familiar with the Crosland thesis that economic growth is the sine qua non: it generates new resources for the welfare infrastructure without the need for unpopular new taxes. Titmuss was also familiar with Galbraith’s contention that the increasing consumption of frivolous baubles is of zero marginal utility: the overdeveloped countries would do well to put social balance through public services above private living standards want-created by advertising. Titmuss was too close to consensus to accept with the puritanical Galbraith that discretionary luxuries had become a false God. Intellectually, at least, he had more in common with the hedonistic Crosland who wanted both public and private sectors to expand in the course of macroeconomic growth. Growth would create a dividend for welfare. Welfare in turn would make a contribution to growth. In suggesting that welfare is not a passenger but a complement, in implying to the market economists that social altruism can be good business as well, Titmuss seems to be arguing almost Crosland-like in support of a welfare capitalism in which even the deprived are empowered to buy and sell.

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Welfare facilitates growth in the case of education and health. It is open to debate whether these publicly provided services are also ‘public goods’ in the strict textbook sense of utilities, nonexhaustible and non-excludable, which must be made available to all if they are to be made available to any. Titmuss does not distinguish adequately between functions that the private market is unable to fulfil (such as the institutionalisation of the indigent into universalist services) and functions that it ought not to fulfil (such as the self-funding of education and health through fees paid by the direct beneficiary alone). What is not open to debate is the contribution of compassion and justice to productivity and profits. Training and retraining make available a pool of transferable skills. The National Health contains infection and minimises work-days lost through illness. Titmuss, referring to welfare, says ‘good drains mean good business’.19 Education and health confirm the existence of the link. As does the Tawney-like open road. Titmuss writes that the equality of opportunity is a ‘democratic precondition of faster economic growth’.20 Not only do good starts and fair races squeeze the most from all grades of talent; the equalisation in itself boosts morale, promotes integration, legitimates meritocracy, defuses class conflict and represses resentment. Growth presupposes mobility. Mobility, in turn, presupposes opportunity: ‘This implies a less class conscious and stratified society, less rigidity in the institutional framework, and fewer privileges which do not derive from the worth and ability of the individual.’21 Socialism is liberalism precisely because achievement is the ultimate bulwark against the alienation of the excluded. Welfare further feeds the process of economic growth to the extent that it smoothes out the personal disappointments and picks up the pieces of shattered expectations: More flexibility and change in the economic world means human stress; more people are going to be hurt . . . If we want flexibility in our economic structure – as I believe we do – then we must also have social policies which ① will reduce and alleviate the stresses that are created ➁ are designed to support and make things easier for people who want to change and ➂ are designed to make things more difficult for those who obstruct others from changing.22

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We as a nation welcome the new products and the new technologies that result from ‘creative destruction’ in the service of more, better, cheaper and different. We as a nation, however, recognise that the costs of the improvement should not fall disproportionately on the individuals who lose out to the competition: ‘Considerations of morality are thus intertwined with considerations of social health; as such, they cannot be subordinate to and separated from considerations of economic efficiency.’23 No, they cannot; but the cost-conscious and the change-minded should nevertheless be made aware that there would be less flexibility, not more, if people were too afraid of losses to take risks. The safety net is a Kantian absolute. It is also an ingredient in economic adaptation. Titmuss says as much: One important element which I hold to be socially and economically desirable is flexibility for I believe that without it there is less freedom; less freedom in all fields – educational, social, economic and political . . . I believe that a flexible and dynamic social policy is a necessary corollary to flexibility in our economic life.24 Not just a corollary but a necessary corollary – and a maximand as well: ‘I consider that social policy . . . must function as an instrument for the encouragement of economic flexibility.’25 Social policy provides a stimulus to growth to the extent that it takes on the kaleidoscopic uncertainties that private insurers would turn down as certain loss-makers. It makes an additional contribution by means of economic welfare. Macroeconomic welfare embodies the commitment to full employment and capacity operation. It ensures a high level of consuming and spending. It leans against the cyclical downswing by means of income replacement that stabilises aggregate demand. It resorts to pay policies to contain inflation without threatening output. Microeconomic welfare is an acknowledgement that individual markets benefit from sensible guidance. Disruptive unions are offered farm price support and subsidised public buses as the quid pro quo for their cooperation in no-strike clauses and the electronic revolution. Regional infrastructure and accelerated depreciation, attracting new industry to unemployment black-spots, protect the remembered reputations and traditional networks that are the productive social capital of the long-lived community. Compulsory seat-belts and taxes on smoking

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at once defend the health status of the individual and minimise the loss of working life. Macroeconomic or microeconomic, the message from economic welfare is a clear one. The more one extends the Titmuss model in line with the spirit if not with the letter of the canonical publications and lectures, the more one is convinced that Titmuss saw his mission not as threatening affluence with justice (in the sense of Galbraith) but as advancing efficiency through equity (the essence of Crosland’s middle-ground mix). It was Titmuss himself, after all, who, searching for ‘the highest possible correlation between economic change and changing social needs’, stated clearly the nature of the outlook that he had made his own: ‘It sees the social services as an ally, rather than as an enemy, of the economic order.’26

Titmuss expected and advocated complementarity. Pierson is only one among many to have said that the relationship is an unsustainable one: ‘In the long term, the welfare state is incompatible with a healthy market-based economy. Only the exceptionally favourable circumstances for economic growth of the post-war period allowed simultaneously for an expansion of the economy and the welfare state.’27 Titmuss on complementarity, Pierson would say, was the optimistic product of ‘you’ve never had it so good’. In the long term, however, welfare is more likely to be a strain. Titmuss on complementarity refers almost exclusively to services. The critics of complementarity refer disproportionately to expense. Welfare must be paid for, and universalism is a bigger commitment than selectivity. The critics of the joint-products position will typically suggest that thinkers like Titmuss fail to see that the economic benefits do not equal or exceed the economic costs. The ethical case for welfare is not affected by the excision of the positive-sum economics. What is lost is the duality of return that makes up the mix. If the nation wants more universalism, it will have Galbraith-like to do without some growth. The funding of welfare is a prominent threat to growth. A budget deficit financed through the borrowing and spending of private savings that would otherwise have been demonetised can unleash a price spiral. Inflation is not just an unfair and a random mode of income redistribution but a serious impediment as well to the market signalling upon which efficient allocation is so dependent. Keynesian borrowing can push up interest rates and crowd the private sector

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out of scarce loanable funds. Should current spending then take the place of capital investment, a slower rate of growth is likely to be the result. The alternative to borrowing is finance raised through tax. Economists tend to regard the quantity supplied of an input as a positive function of its remuneration. The expectation may well be simplistic. People work for prestige, power, promotion and job satisfaction as well as current pay. Also, some at least of the money-minded will respond to a rise in tax through an increase in their overtime and not a decrease in their effort precisely because no household wants to see its living standards fall. The expectation may well be simplistic – but the disincentive to enterprise, initiative, risk-taking, labour supply and productive efficiency may also be a very real one indeed. One person decides not to take on additional responsibility or to acquire a further qualification. Another person turns down a better-paid job because the pre-tax increment is inviting but the post-tax increment is invisible. There can, it would appear, be a certain contradiction between equal opportunity through welfare and the economic incentive to take full advantage of it. Disincentive effects might also obtain in the market for savings (as where households are so discouraged by the punitive taxation of interest, dividends, capital gains and inherited estates that they exchange deferred gratification for present pleasure) and in the case of investment (as where businesses are prevented by high corporation tax from expanding plant out of profits even at the cost of substandard services and a slower rate of increase in employment). Multiple disincentives such as these, conceptually speaking, can have a serious effect on public finance. Where they hold down the expansion in new value-added, the consequence could be a smaller tax take to pay for welfare than would have been available had the tax rates been lower and the growth rates higher. Titmuss clearly did not think that resources spent on welfare could be a serious threat to resources needed for welfare. Conceptually speaking, however, the possibility must be regarded as a lion in the path until the Titmuss model is extended to show that the tax cost is no real brake on the nation’s wealth. The fact that Titmuss favoured direct taxes because they narrowed income differences introduces a further complication into the evaluation of the complementarity thesis. Progressive taxes are socially integrative taxes: not only do they provide finance for welfare but their built-in egalitarianism helps to moderate what Tawney described

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as ‘violent contrasts of wealth and power’.28 Progressive taxes in that way kill two birds with one stone. Tawney accepted that income differentials had an economic function, but urged that they should not be so great as to obscure the common humanity of equal citizens. His declaration that ‘the extremes both of riches and poverty are degrading and anti-social’29 had a profound effect on British Labour, and not least on Titmuss who almost four decades on from Equality echoed it in the following words: ‘History suggests that human nature is not strong enough to maintain itself in true community where great disparities of income and wealth preside.’ 30 Both Tawney and Titmuss wanted non-proportional income taxes to play their part in the planned redistribution of life chances. Neither, however, said just how much cutting down would be required to secure a tolerable measure of social integration – or imagined that recognisably divisive post-tax differentials might be the functional prerequisite for the growth that so greatly simplifies the finance of welfare. Fiscal distance as a topic is by no means an attractive area in which to linger. Envy separates the neighbours: the destruction motive of the indolent and the unambitious is not an uplifting reason for a politics of Schadenfreude to impose a penalty on the successful. Initiative, training and assiduity are causes of high incomes: it seems unkind to punish meritocrats for exceptional responsibility and Sunday overtime. Singers and athletes claim a rent of ability for innate talent and inherited skill: however much it is their genes and not themselves that deserve the surplus, there is no known way of distinguishing the functional minimum from the suprafunctional premium for the purposes of windfall-skimming tax. Fiscal distance as a topic brings out the worst in human nature. All too often the discussion of how to make the most of oneself degenerates into a discussion of how to make the least of someone else. Ethics aside, there is also the economics. Where there is no reduction in the supply of effort, progressive taxes may indeed be able to level and fund without having a negative effect on the rate of growth. Where, however, the consequence of the taxes is underexploited aptitudes and foregone productivity, a genuine conflict may be said to obtain between social and economic objectives which egalitarians like Tawney and Titmuss have been too quick to ignore. The alienation of the higher achievers can be an expensive price to pay for the de-alienation of the more excluded. The achievers feel resentful and wronged. The malintegrated feel second-best as

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ever because of surviving differences in power, in prestige and in income. The nation is sacrificing economic growth to secure felt cohesion but is ending up with neither of the endstates rather than with both. Even steeper tax rates – and an even greater discouragement to the supply of effort – may become the only way to keep an ambitious welfare programme afloat. Cuts are a familiar response to an overexpanded public sector. Titmuss, were he to have addressed the macroeconomics of an overgrown aggregate, would have emphasised that welfare is hardly the only or even the principal component: ‘The cost of the National Health Service (the most expensive of all the social services in Britain) does not amount to more than one-third of total defence expenditure.’31 Titmuss, not a unilateralist, was too much of a Keynesian to reject on principle the stimulus from any major source of spending and control: ‘More than anything else this Defence Budget since 1945 has been responsible for high level of taxation and for management of the economy.’32 Defence to the planner was a plus and not a minus. If cuts had to be made, however, it is clear that Titmuss had in his mind other areas than welfare in the public sector that could better bear the brunt.

Titmuss believed in the complementarity of growth and welfare. Public finance, as has been noted, calls into question the confidence with which a partnership and not a trade-off might reasonably be expected. So does the acknowledgement of professional autonomy. Referring to the private sector, Titmuss writes as if the surgeon has so shaky a professional ethic that he yields to the temptation of biased information and unnecessary treatment in a fee-for-service market. Referring to the state sector, Titmuss writes as if the wasteful commitment of scarce healthcare resources would come to an end once private gain-seeking had been transcended by the socialisation of provision. In neither case is the economics of his position entirely clear-cut. Thus, while the profit-maximising doctor might need to be protected from his own worst self, so might the plumber, the carpenter and the repairman, tempted as each will be to supply slovenly and shoddy workmanship and to replace parts that have not worn out. If the doctor has to be rescued from the corrosive of capitalism, then so too, it is clear, might other information corners in the asymmetrical society. Titmuss is being unfair in trying to have it

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both ways. It is analytically unsatisfactory simply to say that those groups currently sheltered within the Welfare State need help in preserving their fragile ethic while those groups currently exposed to unsentimental rivalry do not. The philosopher must also say why the market fails where it does – and whether the traditional demarcation might not be the perpetuation of a myth. It is the promise of recommendations and repeat business – reinforced as always in the social economy by moral sentiments, by conscience and self-image – that keeps the High Street cobbler from insisting on leather when rubber would easily outlast the shoe. More competition and not less competition might in the same way be the corrective of the economic waste to which Titmuss can see no alternative but the State. Nor is it obvious that professionals when made into civil servants will automatically make the most economic use of their service budgets. One bias will be commission: because the teacher wants to educate and the doctor wants to heal, more resources may be plunged into help and care than the nation as a whole would like to see – or can afford to divert from productive activity that is an immediate source of newly created wealth. Another bias will be omission: where professionals have a guaranteed income with security of tenure, textbook economics would predict that, apathy and indifference facing no pecuniary check, bureaucrats will let productivity levels slip since there is nothing but exertion in the marginal client with the marginal complaint. While euthanasia is cheaper than pensions, it is not necessarily more efficient if we as a nation genuinely want a particular end and not another to be our maximand. Payment without service is not value for money. Waste is not conducive to growth. Titmuss may have underestimated the possibility that an excess of non-productive welfare can slow down the rate of growth of the economy. He may have overestimated the extent to which the valueadding potential of public-sector professionals will escape from the blinkered self-reproduction of trained inertia and from the tyranny of the quiet life. Macroeconomic welfare (which Titmuss takes for granted) can raise the normal level of unemployment and build in the instabilities of the stop–go cycle. Microeconomic welfare (to which Titmuss devotes less attention) can retard flexible adaptation and act as a tax on jobs. Growth and welfare may, in short, be substitutes and not complements as Titmuss so optimistically suggests. That, of course, is no reason not to choose welfare. It is

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only a reminder that social services can cost living standards and that the democratic consensus might not be prepared to make the sacrifice.

(d) Pattern maintenance The key word in Titmuss’s vocabulary is integration. Paradoxically, however, it is integration that is most conspicuously lacking in the cast-iron compartmentalism of his dichotomised world-view. On the one hand there is the market sector, dominated by the laws of supply and demand, characterised by unequal incomes, governed by the norms of self-interest and reciprocity. On the other hand there is the welfare sector, determined to avoid stigma, committed to community and redistribution, governed by the gift relationship and the transfer of service. A mixed economy is also a mixed society. Titmuss may rightly be criticised for not clarifying the relationship between the two sectors which he evidently intended should coexist side by side. One consequence is moral schizophrenia. Living part of his life through monetary exchanges and the other part through stranger gifts, the social actor is not certain how to reconcile the separate standards or to manage his interactions with his fellow citizens. Normative bilingualism is not a problem where the spheres are clearly defined. A child accustomed to speaking Chinese in the home and English at school will not find it difficult to select the appropriate tool. Titmuss on Mammon and Caesar seems to be adopting the same pattern of two places, two norms. The market sector is the sphere of acquisition and ambition: possessive individualism equates getting on with getting ahead. The welfare sector is the sphere of integration and love: the unilateral transfer is the ‘distinguishing mark’33 of a social policy. In the economic market the values of welfare would prove a liability and not an asset: compassion and acceptance are dysfunctional to the efficiency of negotiated exchange. In the Welfare State the aims of capital would be at variance with the needs of the dependent: competition, comparison and profit must give way to community, fraternity and involvement. The two spheres would seem to be clearly defined. The two sectors would seem to be separate compartments, the social manifestations of a cast-iron dichotomy. Moral schizophrenia is not a problem where the spheres are clearly defined. The problem arises once cross-sphere penetration is admitted

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as an intellectual possibility. As soon as the individual is allowed a free choice of his norm, the danger is a real one that citizen-shoppers will become confused as to whether they should love their neighbour as themselves or hold out for the best possible discount. Cast-iron compartmentalism is artificial but it is clear. Unexplained trespass is the institutionalisation of anomie. Titmuss himself describes not just the simultaneous adaptation to two quite different ways of life but also the cross-sphere penetration of the welfare-sector norms. Examining trends in modern Britain, he was able to report that, due to a ‘fusion of intelligence and concern for social justice and equality’, the nation of Tawney, Beveridge and the National Health was already manifesting a ‘growing power of altruism over egoism’.34 What this suggests is that the Welfare State, not paternalist but fraternalist, was making a free gift not just of soup for the down-and-out but of the caring mindset that leads rich countries to write off Third World debt and induces pieceworkers to sacrifice an hour’s pay when they donate their vote. Spanish is the lingua franca in Spain and the yen is the means of payment in Japan – even a child knows that. Unexplained trespass means that all bets are off. Is Titmuss really predicting that the business community will hold back on underselling because a rival is ill? Is Titmuss really proposing that a landlord should pass up the competitive rent because otherwise his tenants will go hungry? All that is certain in the trespassing society is that large numbers of people will not know the dress code or how to behave. Titmuss conceived of trespass in the sense of socialised consumption rehumanising private production. Others, turning the tables, will say that welfare even now is widely perceived as a special case of buying and selling. Patients, it can be argued, look upon the National Health as pre-paid consumption (on the model of a television licence) or as pooled protection (on the model of group-plan insurance): not seeing it as the realm of the sacred, they will situate their waiting times, their bedside manners and their blood transfusions in the tried-and-tested realm of the profane. Taxpayers, likely to think of the social services in terms of taking rather than of giving (and inclined as consumers to vote themselves more of a free good than they as citizens are willing to fund), regard their returns as a burden and not a privilege: sharing can be a source of deep satisfaction to blood Samaritans but taxpayers can be resistant to open cheques written to cover others’ diswelfares. Teachers and nurses, clearly not remunerated by the directly dependent at the service stage,

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cannot realistically be modelled as if volunteers who gift without a fee: strikes, demarcation disputes, overtime bonuses, special payments all show to what extent the values of the economic market have made their way into welfare. Titmuss plays down the cross-sphere penetration of the exchange mindset in areas such as these. Had he acknowledged the permeation, he would have been less confident that the welfare nexus was safe from attack.

T.H. Marshall said that the differing institutional elements in the mixed and hyphenated society were mutually beneficial and mutually supportive: they ‘strengthen the structure because they are complementary rather than divisive’.35 That is why he praised competition for the social uplift that he also expected from the State: ‘The task of banishing poverty from our “ideal type” society must be undertaken jointly by welfare and capitalism; there is no other way.’36 T.H. Marshall was a theorist of intersphere collaboration. Titmuss was a compartmentalist in his sociology and a welfarist in his ethics. Comparing the two authors, Pinker concludes that a crucial difference must be Marshall’s greater openness to a multi-pronged attack: It is this juxtaposition of competition and equality that distinguishes Marshall’s approach from the Titmussian tradition, with its implication that in a better-ordered society the values of the social market would, as it were, take over and dominate those of the economic market. Titmuss’ ideal of social welfare was based on a normatively unitary model of society.37 T.H. Marshall, more tolerant, made his own ideal the compromise of pluralism. Pinker is critical of the tyranny of the either/or: One of the main problems in British social policy and administration is that too many of its practitioners feel that the social services as agencies of both consensus and change have to function in a society whose basic values are antipathetic to its own social policies. This fallacious model is preserved by the practice of treating the economic and social markets as if they were separate institutional entities.38

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The truth is the mix – control with community, liberty with State. Titmuss, Pinker says, weakened both the descriptive and the prescriptive power of his model to the extent that he refused to incorporate the time-honoured halfway-house of moderate interventionism: In my view . . . he oversimplified the general issue by treating it as a choice between no more than two alternatives – the values of the economic market and those of the social market. He thus defined the problem in such a way as either to exclude the middle way of the mixed economy from serious consideration or to place it firmly within the context of the economic market alternative. In so doing he effectively severed the discipline from its most vigorous normative roots.39 Titmuss could have situated the discipline on the middle ground of Keynes and Beveridge. Instead he made the utilitarian market into the sworn enemy of social welfare and ruled out on principle the possibility of a fruitful collaboration. Pinker is unconvinced that the dichotomy which Titmuss postulates is a meaningful one: ‘He uses the terms “altruism” and “egoism” in such a way as to describe a polarity of sentiments and motives, which in the real world are more likely to be interactive and conditional.’40 Nor is Pinker convinced that the altruism of, say, the kidney donor is always and everywhere a morally justified thing: ‘A potential donor would have to consider very carefully the extent to which he is morally justified in placing at risk the welfare and security of his own family in order to save the life of a stranger.’41 The analytical distinction is oversimplified. Mixed motivation is artificially compartmentalised. Pragmatism gives way to an invariant a priori. Exchange is seen in a negative light. Admiring Titmuss as he does, Pinker would evidently want to relax the either/or perspective of a model on the defensive in order to maximise the welfare gains that the society can reap from all of its sectors.

Titmuss wrote like a man surrounded by enemies. If the perspective is so frequently that of a world-view under assault, the reason is that Titmuss saw himself as fighting a rearguard action against a savage army of Economic Men for whom kindliness was no good substitute for cash.

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Historically speaking, it was indeed the message of the Victorian marketeers that commercial values are good and dependency on the State a shameful admission of defeat. Titmuss, like Galbraith, believed that the economists of his own time had become trapped in the acquisitive anti-Statism that even in Victorian times hardly represented a very lofty ideal: Most of the pleasurable (and I may add financially rewarding) model building which economists are so prone to indulge in seems to me to rest on a vague Victorian concept of the average worker – a worker who is assumed, above all, to be an unattached individual, socially rootless, highly mobile, biologically youthful and seized with ambitions to get on, accumulate property and save, in an English climate, for a series of rainy days for which neither Heaven nor a Welfare State provided any umbrella.42 The economists of the past had become the economists of the present. The colleague at the School of Robbins, Plant and Yamey, Titmuss was convinced that nothing had changed in a hundred years. That being the case, the decent welfarist had also to become a polemicist, hammering home the message that no one could be a T.H. Marshall – or a Pinker – while the enemy was still planning to re-Victorianise the great social gains of Attlee and Bevan. Titmuss discovered to his cost what it meant to take on the new freedom from. The Institute of Economic Affairs had been founded in 1957 by Ralph Harris and Arthur Seldon. The first of a number of pro-market research associations (it was followed later by new think-tanks such as the Adam Smith Institute and the Centre for Policy Studies), it sought to challenge the middle-ground consensus at a time when there was not a great deal of clear water between Macmillan and Crosland. Harris and Seldon were impressed by the proposal for welfare vouchers that had been outlined (inspired by a suggestion made by Adam Smith) by the young Milton Friedman in 1955. They were intrigued by the possibility that health and education could be allocated like all other consumer goods, not as free public services but as economic choices to be paid for through fees. Health Through Choice (1961) by D.S. Lees is an early example of an Institute publication. Its defence of private insurance and means-tested assistance is precisely the kind of policy initiative which made Titmuss fear that the Victorians were once again at the gate.

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The Institute declared itself to be pro-market but not partypolitical. As far as Titmuss was concerned, it was certainly not proLabour. His imputation, in an article of 1963 entitled ‘Ethics and Economics of Medical Care’, that it had a connection with the Conservative and/or the Liberal Party, had unreservedly to be withdrawn after Titmuss was threatened with libel action which could have been financially ruinous. 43 Private correspondence with R.H.S. Crossman44 and S.M. Miller45 reveals that Titmuss felt he had been forced to back down because of the unequal economic position. Titmuss never accepted that the funding of the IEA was entirely above board. He seems in particular to have suspected certain American donor organisations of being front organisations for the CIA. He never found any evidence to bear out his belief. The IEA refused to let the matter rest with an apology. In 1964 J. Jewkes, D.S. Lees and A. Kemp all contributed replies to the 1963 paper. Published in Medical Care, they were immediately republished by the IEA as Monopoly or Choice in Health Services? Titmuss did not allow his earlier contribution to be included but about half was reprinted none the less as ‘fair comment’. Titmuss in that way became an IEA author. He knew that he could not afford to take legal action for possible breach of copyright. The most he could do was to write a strongly worded letter of protest (published in The Spectator of 17 April 1964) and to send a note to all of the members of the IEA Council. Even the more sympathetic of the Council members felt that Titmuss was exaggerating the problem. Colin Clark wrote an especially conciliatory reply indicating to Titmuss that no real harm had been done: ‘I received your duplicated note and don’t see why you are so worried. Albeit in a confused form, you were able to get your case stated to I.E.A. readers, and I for one found a lot in it, particularly about the high expenses of private non-group insurance in U.S.A.’46 Titmuss for his own part continued to believe that the Institute had behaved dishonourably and had shown a bias. As he told Melvin Lasky in 1967 (Titmuss was declining to reply in Encounter to Seldon’s ‘Crisis in the Welfare State’ because he feared a libel suit): ‘It is virtually impossible to conduct anything like a rational discussion with Mr. Seldon and his colleagues at the Institute of Economic Affairs. Evidence is ignored, facts avoided and critical questions left unanswered.’47 Mr Seldon and his colleagues were probably saying much the same about Titmuss; and so, one would guess, were Robbins, Plant

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and Yamey at the School. The important point is that ideology had not entirely come to an end even in the consensual Britain of Titmuss’s LSE maturity. The Victorians, like the poor, had not withered away. Titmuss may have overpolarised the choices and underestimated the market. Yet he had to do so. He was forced into the either/or because the lasting peace had not yet been won.

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16 Conclusion

Richard Titmuss wrote no single text that would unify his disparate insights. This book has sought to reconstruct the text that never was. Part One defined social policy in terms of value consensus and argued that Titmuss made generalism, humanism, relevance and scepticism the core considerations that should inform a socially useful methodology. Part Two considered the stigma of selectivity and showed why Titmuss believed means-testing to be a threat to self-respect. Part Three, dealing with universalism, explained that Titmuss defended his common infrastructure of social services in terms of social costs compensated for by social benefits, citizenship integration fostered by overlapping experiences, planned redistribution delivered by means of selective discrimination. Part Four, turning to economics, established that the welfare market had failed in precisely those areas where its libertarian advocates had most expected it to succeed, in respect of quality, choice, quantity and price. The system is an ambitious one, global and comprehensive. Titmuss’s system is the best we have. Assuming that the reconstruction attempted in the present book is in line with the construction that Titmuss himself would have intended, what is clear is that no one either before Richard Titmuss or since his death has produced an intellectual map capable of situating and integrating so large a number of seemingly unconnected variables in the all-encompassing inquiry into welfare and society. As well as reconstructing the hidden general theory, this book has sought to evaluate the system and to suggest ways in which it can be extended. Presenting no new evidence and testing no concrete hypotheses, the discussion in Chapters 4, 6, 10 and 15 must necessarily be more tentative and exploratory than in the others. 269

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The chapters draw on unpublished lectures and other notes to show that even Titmuss was consistently developing his model beyond the borders delimited in the publications. The chapters make comparisons with Tawney and other social democrats to show that Titmuss, original as he was, was part of an organicist tradition which believed in common institutions because they were the effect and cause of the common culture. The impression that emerges from the four chapters on evaluation and extension is that Titmuss was too optimistic about welfare, too hard on exchange; but that the framework is flexible enough to allow for a considerable measure of modification. What cannot be modified is the conservatism. Titmuss was a social-ist even before he was a socialist. The one thing that cannot be grafted on to the model is the rootless individual, cut off from the past and insensitive to his neighbours, who lives only for himself today.

Titmuss used the National Health as the paradigm for the national health. He thought big, as he promised he would do in his historic Fabian manifesto on The Irresponsible Society. There, in 1959, he had declared: ‘One of the most important tasks of socialists in the 1960s will be to re-define and restate the inherent illogicalities and contradictions in the managerial capitalist system as it is developing within the social structure of contemporary Britain.’1 Titmuss did not complete his account of social responsibility. Others will have to do so. Some will be socialists, at one with Titmuss on the ‘illogicalities’ and the ‘contradictions’. Others will be non-socialists, taking from Titmuss the no less prominent lesson that welfare is incomprehensible where it is denied its socio-economic context. In building upon Titmuss, there are two contributions of particular interest to students from a range of ideological perspectives who want to see the dependent as if they were real people like the PhD candidates who squeeze a promotion from broken lives.

(a) Social science and social philosophy Titmuss secured an enviable marriage between social science and social philosophy. As a scientist he recognised that the proclamation of principles is no substitute for disciplined thought supported by empirical evidence. As a philosopher he returned to the traditional

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socialist preoccupation with social justice, human equality, citizenship rights, the sense of community and the equitable distribution of power. As a broker between science and philosophy, he believed that men can and do change their minds and then their societies as well; that the driving force behind this change is logic and persuasion; and that bias and ignorance can usually be overcome by informed discussion based on the facts. This missionary zeal to reform society collectively but by peaceful academic means underlies much of his scientific work. Titmuss stressed that, whether for description or prescription, the facts are essential if meaningful conclusions are to be drawn and useful recommendations made. He and his colleagues are to be credited with a vast body of scholarly research noteworthy for its high quality and cutting-edge relevance. It would be incorrect to say (as some pure academic sociologists have on occasion suggested) that he and his followers were excessively concerned with policy questions reflecting their own political bias. It would, however, be true to say that Titmuss did see science as the servant of society, and that many of the questions he asked definitely had moral overtones and were value-laden. This would include the core question of how to eliminate stigma and promote integration, an explicandum which presupposes that spoiled identity and detachment from the community are always bad by definition and require no further probe. It would also be true to say that Titmuss sought to reform the public consciousness as a first step towards major social reform. This he succeeded in doing not least through his literary style. His books are provocative and stimulating, even to the general reader. The blend of perspectives and principles with a mass of information makes them interesting and often eloquent. They demonstrate how academic methods can shed light on practical problems and prove that ideas do have consequences. Thus Titmuss’s Report in 1961 to the Government of Mauritius, which identified family size and population pressure as that island’s main social problem, could have had far-reaching implications. His recommendations for the three-child family were not in the end adopted. Population growth, fortunately enough, fell dramatically even without the guidance of policy. It was 3.5 per cent per annum in 1956. It was only 1.3 per cent per annum in 1971.2 Again, Income Distribution and Social Change proved a valuable and influential attempt to go behind the veil of official statistics and study the social structures which the numbers conceal. In that

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book Titmuss put his intimate knowledge of the complexities of taxation and insurance to good use and made some significant calculations and observations. The work may be criticised for the wealth of marginal data that it mobilises on relatively small abuses (such as the fact that the expense allowance paid to members of the House of Lords is tax-free) and also for its failure to make ambitious original proposals for fiscal reform. It is almost certain, however, that it led directly to the elimination of some of the inequalities perpetuated by the tax system and by the rich who are able to manipulate it. Titmuss’s book to that extent played a role with respect to relative deprivation which recalls that played at an earlier date by the work of Charles Booth and Seebohm Rowntree in the field of absolute poverty. Titmuss, Booth and Rowntree had much in common. All three were not merely collectors of data and sifters of evidence but discontents who used the facts they discovered to attack the complacency of laissez-faire economic and social doctrines. All three explained deprivation (whether absolute or relative) in terms of social causes rather than individual failings. All three faced the future with an optimism born of belief in the power of persuasion in a humane and democratic society. A reluctance to separate description and prescription, induction and reform is very much a part of the British tradition in social policy. Most spectacularly, The Gift Relationship demonstrated statistically the importance of humanitarianism and the prevalence of altruism. It showed that compassion is economically efficient where private markets based on self-love are not. It actually led to a re-examination of commercial blood banks in the United States (where the book became a bestseller and prompted Elliot Richardson, then Secretary of State for Health, Education and Welfare, to consult Titmuss personally on questions of reform). The book demonstrated (at least to its author) that values and ideologies display no tendency either to disappear or to converge. It was in many respects the culminating achievement in Titmuss’s lifetime campaign to cajole and convince through rational argument buttressed by hard evidence. It combined useful survey techniques with a comparative approach (albeit mainly with the United States, partly because of the accessibility of information, partly because the strong market orientation of the American Dream served as a tempting target). It was particularly persuasive by virtue of its multidisciplinary and interdisciplinary perspectives, attempting as it did to break down artificial barriers between economics, sociology, anthropology, philosophy, law and

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medicine. The resulting synthesis certainly raised both the intellectual level and the moral tone of political argument. Scientifically speaking, the gift-nexus is in practice probably not as Titmuss alleged it to be. Ethically speaking, it undoubtedly ought to be.

(b) The importance of social theory Titmuss believed that social policy as a subject should do more than simply equip midwives, social workers and other welfare professionals with the skills they would need to treat the symptoms of misery. It should also as a subject be able to explain and predict the incidence and the causes of distress. For this reason he argued that the careful collection of information by itself is no more enlightening than the ad hoc and the ad hominem: a sound body of social theory is the essential precondition for meaningful selection, organisation and interpretation of the results of empirical investigation. Titmuss himself attempted to develop such a body of theory. The intellectual framework involves structure, function and role, but also ideology and belief, which Titmuss regarded as essential to a young subject where theory had tended to lag behind practice. He warned that ‘the social scientist without an ideological frame of reference rarely asks good questions’.3 He attacked the descriptive and dehumanised approach where ‘the “how” and the “why” of social policy, the movement of ideas and forces which shape social law, are submerged in a mass of factual information. The dilemmas of equity and the conflicts of power are hidden; what remains is dull and it is comforting.’4 Titmuss was a theorist concerned with some of the most fundamental concepts in the sociological tradition. For this reason it may be that he never entirely believed that social policy was in need of an independent body of theory of its own. Of course, he was a theorist of intervention starting from a premise held by hardly any of the founding fathers, that harmonious change presupposes substantial government direction. In arriving at this premise he had been exposed to two unique phenomena, Keynesian economics and the post-war Welfare State, which the founding fathers had not anticipated. Even so, and apart from the question of state intervention, it is striking how much of his work was influenced by the classics, particularly by Durkheim and Weber. Like Durkheim, Titmuss believed that society is a reality in its own right (sui generis); that social facts can only be explained through

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reference to other social facts; and that collective rather than individual causes – and solutions – must be found for non-ego social problems. Like Durkheim, he argued that what people think is as important as what people do: the social scientist cannot afford to neglect people’s (subjective) perceptions and valuations any more than he can afford to neglect their (objective) behaviour patterns. Like Durkheim, Titmuss recognised that a sense of resentment could develop where people are not given equal opportunities to fulfil their potential (i.e. where there is a ‘forced division of labour’), but (again like Durkheim) he had little interest in class conflict between capital and labour. Like Durkheim, Titmuss identified the threat of anomie (a lack of sufficient social integration) in a changing industrial society; accepted the existence of social purposes higher than the economic aims of acquisition and enjoyment; and argued that these social purposes should be derived from an internalised value-consensus or conscience collective. Like Durkheim, he noted that economic individualism is often difficult to reconcile with moral community. Like Durkheim, he none the less recommended that individualism be given an important role to play in the interest of progress. Like Durkheim, he had little idea of the resources constraint. Titmuss only shows a real awareness of scarcity in work done with Brian Abel-Smith, a Cambridge economics graduate. In common with the older Durkheim, Titmuss believed in the importance of mechanical solidarity (solidarity based on resemblance rather than on differentiation and interdependence). Both men advocated an institutional remedy to the problem of normlessness: just as the school itself (and quite apart from the lessons it provides) has an integrative function for Durkheim, so the National Health Service and the other institutions of the Welfare State have a socialising function for Titmuss. Both men recommended collective pressures to counteract the threat to the professional ethic from the market mechanism. Neither believed that the market by itself would be strong enough to ensure acceptable standards. The main difference between Titmuss and Durkheim seems to lie in the nature of provision. Durkheim advocated public education but was prepared to leave many other forms of welfare in the hands of guild-like intermediate groups or ‘corporations’. Titmuss, on the other hand, had a wider conception of social welfare. He believed that welfare should be macrosociological, aimed at the national community and provided by it. Because he believed

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welfare to be a social rather than a professional or an occupational concern, he would have been adverse to any move towards corporate provision. As well as with Durkheim, Titmuss shared some of his most fundamental theoretical concepts with Max Weber. Both men believed that science cannot be value-free but that the social scientist should make his personal values clear and attempt to distinguish his empirical evidence from his moral beliefs. Both had a subjectivist and idealist bias, and stressed how often ideas lead to action. Both put bureaucracy at the centre of their model (Germany in the time of Weber already had a national insurance system, and it was itself highly bureaucratised). Both emphasised that private-sector bureaucracies are no less bureaucratic than are state-sector bureaucracies. Both believed in the need for a nation to identify collective ends. Both tended therefore to assign an important role to the political leadership. Both Titmuss and Weber liked history for its own sake and as a guide to the future. Both were scrupulous collectors and collators of information, but neither was afraid to draw lessons from the data or mobilise facts in the service of a political cause. Both were generalists who attempted to integrate economy and society into a multidisciplinary matrix. If he was influenced positively by Durkheim and Weber, Titmuss was influenced negatively by liberal utilitarianism and exchange theory. He was repelled by the reductionism of individual (consumer) sovereignty, the invisible hand, natural self-interest; refused to use the isolated individual (the economist’s methodological bedrock) as his unit of analysis; and was in that way hostile to the market mechanism on ethical and sociological as well as, of course, strictly economic grounds. It is important to realise that he regarded the liberal utilitarian positivist theory of action of the economics textbook not merely as different in normative orientation from the unilateral transfers of the welfare sector but as inferior to them. If Titmuss was influenced negatively by liberal utilitarianism, then it would have to be said that he was hardly influenced at all by Marx. Marxian ideas such as the basis/superstructure relationship, exploitation, surplus value, the class struggle, the limitations of parliamentary socialism, the inevitability of revolution are conspicuous by their absence. So too is serious discussion of alienation brought on by the production-line repression of self. Titmuss does not even hint that denial of participation in organisational decision-making

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or the closing off of any opportunity to feel creative and wanted at work could be the cause of many of the problems that are treated in the welfare sector. Titmuss was not a Marxist because of his strong faith in parliamentary democracy. The metaphysical speculation and massive system-building of the Marxists would have appealed to him as little as did Parsonian ‘grand theory’. Through his distaste for Marxism, Titmuss helped to preserve the traditional link in Britain between social welfare and democratic socialism. It is too easily forgotten that British socialism, unlike some of its continental counterparts, has its roots not in Das Kapital but in the Tolpuddle martyrs and the chapels of South Wales. Like many other British socialists, Titmuss was writing in the shadow of the Bible, with its emphasis on community, responsibility, duty, sin, guilt and its stress that the act of giving is somehow good in itself. Perhaps in the last analysis Titmuss can only fully be understood if one interprets his life’s work as an attempt to find a collective response to Cain’s perceptive question on the nature of social welfare: ‘Am I my brother’s keeper?’

Abbreviations of Books by R.M. Titmuss BPW

Birth, Poverty and Wealth (London: Hamish Hamilton Medical Books, 1943)

CW

Commitment to Welfare (London: George Allen and Unwin Ltd, 1968)

Cost

The Cost of the National Health Service (with B. Abel-Smith) (Cambridge: Cambridge University Press, 1956)

EWS

Essays on ‘The Welfare State’, 2nd edn (London: George Allen and Unwin Ltd, 1963)

GR

The Gift Relationship (London: George Allen and Unwin Ltd, 1970)

HST

The Health Services of Tanganyika (with B. Abel-Smith, G. Macdonald, A. Williams and C. Ward) (London: Pitman Medical Publishing Co. Ltd, 1964)

IDSC

Income Distribution and Social Change (London: George Allen and Unwin Ltd, 1962)

IS

The Irresponsible Society (Fabian Tract 323, 1960, reprinted in EWS)

OFP

Our Food Problem (with F. Le Gros Clark) (London: Pelican Books, 1939)

PP

Poverty and Population (London: Macmillan, 1938)

PR

Parents Revolt (with Kay Titmuss) (London: Secker and Warburg, 1942)

PSP

Problems of Social Policy (London: His Majesty’s Stationery Office and Longmans, Green and Co., 1950)

RL

Report on Luton (with Fred Grundy) (Luton: The Leagrave Press, 1945)

SP

Social Policy (ed. by B. Abel-Smith and K. Titmuss) (London: George Allen and Unwin Ltd, 1974)

SPPGM

Social Policies and Population Growth in Mauritius (with B. AbelSmith and T. Lynes) (London: Methuen and Co. Ltd, 1961)

TP

Papers of Richard Titmuss, in the British Library of Political and Economic Science, London School of Economics 277

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Notes 1. Introduction 1 A. Oakley, Man and Wife: Richard and Kay Titmuss (London: HarperCollins, 1996, p. 2). 2 R. Pinker, Preface to D.A. Reisman, Richard Titmuss: Welfare and Society, first edn (London: Heinemann Educational Books, 1977), p. vii. 3 D. Donnison, ‘Richard Titmuss’, New Society, Vol. 24, 12 April 1973, p. 81. 4 B. Abel-Smith and Kay Titmuss, Preface to their The Philosophy of Welfare: Selected Writings of Richard M. Titmuss (London: Allen and Unwin, 1987), p. xii. 5 Pinker, op. cit., p. vii. 6 Ibid., p. xii. 7 H. Rose, ‘Rereading Titmuss: The Sexual Division of Welfare’, Journal of Social Policy, Vol. 10, 1981, p. 478. 8 P. Wilding, ‘Titmuss’, in V. George and R. Page, eds., Modern Thinkers on Welfare (London: Prentice Hall/Harvester Wheatsheaf, 1995), p. 156. 9 Ibid., p. 150. 10 P. Wilding, ‘Richard Titmuss and Social Welfare’, Social and Economic Administration, Vol. 10, 1976, p. 149. 11 R. Mishra, The Welfare State in Crisis (Brighton: Harvester, 1984), p. 131. 12 Abel-Smith and Kay Titmuss, loc. cit., p. xii. 13 CW, p. 7. 14 A. Oakley, Taking it like a Woman (London: Jonathan Cape, 1984), p. 6. 15 Oakley, Man and Wife, op. cit., p. 23. 16 Oakley, Taking it like a Woman, op. cit., p. 14. 17 PP, pp. x–xi. 18 Oakley, Man and Wife, op. cit., p. 9. 19 Ibid., p. 8. 20 M. Gowing, ‘Richard Morris Titmuss’, Proceedings of the British Academy, Vol. LXI, 1975, p. 29. 21 Oakley, Man and Wife, op. cit., p. 12. 22 Ibid., p. 288. 23 Ibid., p. 63. 24 Ibid., p. 25. 25 Cited in ibid., p. 33. 26 Cited in ibid., p. 65. 27 Cited in ibid., p. 121. 28 F. Galton, Inquiries into Human Faculty and its Development (London: Macmillan, 1883), p. 241. 29 PP, p. 253. 30 Cited in PP, p. 18. 278

Notes 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67

68 69 70

279

PP, pp. 131,132. PP, p. 16. PP, p. 40. PP, p. 188. PP, p. 152. OFT, pp. 91–2. OFT, p. 94. R.H. Tawney, Equality (1931), 4th edn (London: George Allen and Unwin Ltd, 1964), p. 43. OFT, p. 96. PR, p. 14. PR, p. 35. PR, p. 12. PR, p. 86. PR, p. 87. PR, p. 18. PR, p. 116. PR, p. 109. B. Webb, Preface to PR, p. 10. Ibid. PR, p. 73. PR, p. 67. PR, p. 112. PR, p. 120. PR, p. 92. PR, p. 13. PR, p. 121. R.M. Titmuss, ‘The End of Economic Parenthood’, New Statesman and Nation, 9 August 1941, p. 130. R.H. Tawney, The Acquisitive Society (1921) (London: Collins, 1961), p. 48. BPW, p. 68. BPW, p. 63. BPW, p. 33. BPW, p. 54. The North was divided into four sub-regions. BPW, p. 53. PR, p. 15. Those words date from the same year as the Beveridge Report. BPW, pp. 55–6. BPW, p. 33. R.H. Tawney, ‘Poverty as an Industrial Problem’ (1913), in R.H. Tawney, The American Labour Movement and Other Essays, ed. by J.M. Winter (Brighton: Harvester, 1979), p. 112. BPW, p. 15. W.K. Hancock, Country and Calling (London: Faber and Faber, 1954), p. 194. R.H. Tawney, ‘The War and the People’, New Statesman and Nation, 22 April 1950, p. 454. It is indicative of Titmuss’s relative anonymity in 1950 that Tawney throughout the seven-column review article consistently misspells his name.

280 71 72 73 74 75 76 77 78 79 80 81 82 83

Richard Titmuss RL, p. 125. Cited in Oakley, Man and Wife, op. cit., p. 221. Ibid., p. 289. Oakley, Taking it like a Woman, op. cit., p. 7. Cited in Oakley, Man and Wife, op. cit., p. 3. Oakley, Taking it like a Woman, op. cit., p. 32. Rose, ‘Rereading Titmuss’, loc. cit., p. 482. Ibid., p. 483. Ibid., p. 484. Pinker, op. cit., p. vii. Gowing, ‘Richard Morris Titmuss’, loc. cit., p. 27. Cited in Oakley, Taking it like a Woman, op. cit., p. 111. Wilding, ‘Titmuss’, loc. cit., p. 156.

2. The Definition of Social Policy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

SP, p. 24. SP, p. 131. SP, p. 27. SP, p. 16. SP, p. 22. SP, p. 16. EWS, p. 39. CW, p. 22. CW, p. 131. SP, p. 57–8. EWS, p. 42. EWS, p. 42. SP, p. 141. EWS, p. 39. EWS, p. 40. CW, p. 81. EWS, p. 40. CW, p. 93. R.M. Titmuss, ‘Goals of Today’s Welfare State’, in P. Anderson and R. Blackburn, eds, Towards Socialism (London: Fontana, 1965), p. 354. EWS, pp. 22–3. PSP, p. 133. EWS, p. 85. PSP, p. 506. PSP, p. 507. PSP, pp. 506–7. PSP, p. 508. Cited in PSP, p. 508. PSP, p. 508. R.M. Titmuss, Introduction to R.H. Tawney, Equality (London: George Allen and Unwin Ltd, 1964), p. 10. GR, p. 173.

Notes 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

GR, p. 173. GR, p. 173. Introduction to Equality, p. 14. Ibid. SP, p. 16. SP, p. 136. CW, p. 69. SP, p. 52. CW, p. 185. SPPGM, p. 187. HST, p. 95. SPPGM, p. 107. SPPGM, pp. 130–1. SPPGM, p. 135. SPPGM, pp. 136–7. SPPGM, p. 130. SPPGM, p. 242. SPPGM, p. 182. SPPGM, p. 182. GR, p. 159. GR, p. 198. GR, p. 198. GR, pp. 198–9. GR, p. 199. GR, p. 199. EWS, p. 20. CW, p. 35. GR, p. 224. CW, p. 151. GR, p. 187. SP, p. 27. CW, p. 116. SP, p. 103. Introduction to Equality, p. 14.

3. Some Methodological Considerations 1 2 3 4 5 6 7 8 9 10 11

SP, p. 15. SP, p. 57. SP, p. 51. CW, p. 21. SP, p. 51. CW, p. 13. CW, p. 18. EWS, p. 111. CW, p. 42. CW, p. 72. CW, p. 85.

281

282 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Richard Titmuss CW, p. 41. PSP, p. 218. PSP, p. 342. CW, p. 29. CW, p. 34. CW, p. 31. CW, p. 29. CW, p. 52. CW, p. 20. CW, p. 19. IS, p. 221. IS, p. 222. SP, p. 66. ‘Goals of Today’s Welfare State’, p. 355. CW, p. 25. CW, p. 14. CW, p. 39. CW, p. 42. ‘Goals of Today’s Welfare State’, p. 354. Ibid., p. 362. CW, p. 43. PSP, p. 88. CW, p. 104. SP, p. 52. SP, p. 53. SP, pp. 53–4. CW, p. 31. CW, p. 223. CW, p. 223. CW, p. 40. EWS, p. 33.

4. Part One: Evaluations and Extensions 1 2 3

4 5 6 7

8 9

CW, p. 22. CW, p. 18. ‘Major Goals in To-day’s Welfare State’, unpublished lecture to a seminar on Objectives of Social Services in Israel, Hebrew University of Jerusalem, August 1964, in TP 3/370. CW, p. 150. ‘The Social Services’, unpublished lecture in Edinburgh, n.d., probably late 1950s, in TP 3/370. Ibid. ‘Social Policies in Britain’, unpublished lecture to Greek civil servants at the Royal Institute of Public Administration, Spring 1967, in TP 3/370. ‘Major Goals in To-day’s Welfare State’, op. cit. ‘The Social Services’, op. cit.

Notes

283

10 ‘Social Needs and Costs: An Essay in Confusion’, unpublished paper, n.d., probably early 1950s, in TP 3/370. 11 Ibid. 12 Ibid. 13 Tawney, Equality, op. cit., p. 186. 14 ‘The Direction of Social Policy’, unpublished talk to the Oxford University Labour Club, probably 1958, in TP 3/376. 15 R.M. Titmuss, ‘Social Security and the Six’, New Society, 11 November 1971, p. 929. 16 ‘The Social Division of Welfare’, unpublished lecture in Copenhagen, n.d., TP 3/370. Despite its title, this is not the Eleanor Rathbone Lecture of 1955, reprinted in EWS. 17 Unpublished lecture, no title, to students from European universities, LSE, 16 October 1963, in TP 3/370. 18 Ibid. 19 ‘The Social Division of Welfare’, op. cit. 20 Unpublished lecture to students from European universities, op. cit. 21 Ibid. 22 Ibid. 23 ‘The Social Division of Welfare’, op. cit. 24 J.M. Keynes, The General Theory of Employment, Interest and Money (1936), in The Collected Writings of John Maynard Keynes, Vol. VIII (London: Macmillan, 1973), p. 372. 25 W.H. Beveridge, Social Insurance and Allied Services (Cmd. 6404) (London: His Majesty’s Stationery Office, 1942), p. 163. 26 Ibid., p. 170. 27 W.H. Beveridge, Full Employment in a Free Society (London: George Allen and Unwin, 1944), pp. 121, 122. 28 W.H. Beveridge, Voluntary Action (London: George Allen and Unwin, 1948), p. 319. 29 Beveridge, Full Employment in a Free Society, op. cit., p. 18. 30 ‘The Social Division of Welfare’, op. cit. 31 ‘Aspects of Social Change’, unpublished lecture to the British Council, London, 8 July 1954, in TP 3/369. 32 Ibid. 33 ‘Ten Years of “The Welfare State”’, BBC talk broadcast on 3 July 1958, in TP 2/130. 34 ‘The Irresponsible Society: Re-Assessment’, lecture to the Workers’ Educational Association (London District), 31 October 1962, in TP 3/370. Five lectures were organised by the WEA to discuss the ideas in Titmuss’s Fabian Tract three years after the original lecture. Apart from Titmuss, the speakers in the series were Barbara Wootton, Allan Flanders, Lord Francis-Williams and Harold Wilson. 35 W. Temple, Christianity and Social Order (1942) (Harmondsworth: Penguin Books, 1956), p. 17. The much-cited declaration ‘In place of the conception of the Power-State we are led to that of the Welfare-State’ may be found in his Citizen and Churchman (London: Eyre and Spottiswoode, 1941), p. 36. 36 Tawney, Acquisitive Society, op. cit., p. 48.

284

Richard Titmuss

37 J.M. Winter and D.M. Joslin, eds, R.H. Tawney’s Commonplace Book (1912– 1914) (Cambridge: Cambridge University Press, 1972), pp. 53–4. 38 EWS, p. 42. 39 ‘English Society To-day and Tomorrow’, unpublished lecture to the Extra-Mural Department, University of London, 7 February 1954, in TP 3/370. 40 Letter to J.H. Robb dated 21 September 1959, in TP 2/130. 41 GR, p. 224. 42 Beveridge, Voluntary Action, op. cit., p. 320. 43 Ibid., p. 322. 44 Ibid., p. 319. 45 Ibid. 46 Ibid., p. 58. 47 Ibid., p. 322. 48 Ibid., p. 324. 49 Ibid., p. 320. 50 Ibid., p. 324. 51 Tawney, Equality, loc. cit., p. 43. 52 P. Townsend, ‘Politics and Social Policy: An Interview’, Politics and Power, Vol. 2, 1980, p. 107. 53 I. Illich, Limits to Medicine (Harmondsworth: Penguin Books, 1977), p. 239. 54 Cited in M.L. Johnson, ‘Patients: Receivers or Participants?’, in K. Barnard and K. Lee, eds, Conflicts in the National Health Service (London: Croom Helm, 1977), p. 74. 55 ‘The Relevance of Studies in Social Administration to the Problems of Development’, unpublished lecture at the LSE, 18 October 1965, in TP 3/370. The lecture also includes the reassurance to the students that they are in the right room: ‘S[ocial] A[dministrators] do not have this caste-spirit built into them.’ 56 Rose, ‘Rereading Titmuss’, loc. cit., p. 481. 57 Welcoming Talk to Students on the Approved Schools Course, LSE, n.d., probably 1950s, in TP 3/370. 58 ‘The Family in the Welfare State’, unpublished lecture, 1952, in TP 3/371. 59 ‘The Family as a Social Institution’, unpublished lecture to the British National Conference on Social Work, 1954, in TP 3/371. 60 EWS, p. 103. 61 ‘Trends in Social Policy since 1948’, unpublished lecture in a University of London Extra-Mural Series on Ten Years of the Welfare State, 1958, in TP 3/375. 62 Oakley, Man and Wife, op. cit., p. 11. 63 Ibid., p. 4. 64 EWS, p. 103. 65 ‘The Social Division of Welfare’, op. cit. 66 ‘Social Needs and Costs’, op. cit. 67 ‘Trends in Social Policy Since 1948’, op. cit. 68 ‘The Growth of Social Policy’, unpublished lecture, July 1958, in TP 3/374.

Notes

285

69 L. Doyal and I. Gough, A Theory of Human Need (Basingstoke: Macmillan, 1991), p. 42. 70 ‘The Social Services’, op. cit. 71 Ibid. 72 Ibid. 73 Ibid. 74 Ibid. 75 EWS, p. 39. 76 ‘The Social Services’, op. cit. 77 J.M. Buchanan, Liberty, Market and State (Brighton: Wheatsheaf, 1986), p. 51. 78 See A.H. Maslow, Motivation and Personality, 2nd edn (New York: Harper and Row, 1970), esp. Chs 2–5. 79 CW, p. 195. 80 ‘Ten Years of “The Welfare State”’, op. cit. 81 ‘Equality – Britain and the U.S.A.’, unpublished lecture, n.d., probably 1960s, in TP 3/370. 82 ‘The Direction of Social Policy’, op. cit. 83 ‘The Irresponsible Society: Re-Assessment’, op. cit. 84 G. Myrdal, Beyond the Welfare State (London: Methuen, 1960), pp. 63–4. 85 ‘The Family as a Social Institution’, op. cit. 86 ‘Equality and Community’, unpublished lecture, probably given in Tanganyika, n.d., possibly 1970s, in TP 3/370. 87 EWS, p. 19. 88 T.H. Marshall, The Right to Welfare and Other Essays (London: Heinemann Educational Books, 1981), p. 71. 89 Ibid., p. 109. 90 Ibid., p. 113. 91 Ibid. 92 Ibid., p. 107. 93 Ibid., p. 114. 94 R.H. Tawney, ‘Social Democracy in Britain’ (1949), in his The Radical Tradition, ed. by R. Hinden (Harmondsworth: Penguin Books, 1966), p. 172. 95 J. O’Connor, The Fiscal Crisis of the State (New York: St Martin’s Press, 1973), p. 1. 96 A. Downs, ‘Why The Government Budget Is Too Small In A Democracy’, World Politics, Vol. 12, 1960, p. 544. See also A. Downs, An Economic Theory of Democracy (New York: Harper and Row, 1957) and D.A. Reisman, Theories of Collective Action: Downs, Olson and Hirsch (London: Macmillan, 1990). 97 K. Marx and F. Engels, The Communist Manifesto (1848), in Karl Marx, Selected Works (London: Lawrence and Wishart Ltd, 1942), Vol. I, p. 207. 98 J.M. Buchanan, The Limits of Liberty (Chicago: University of Chicago Press, 1975), p. 157. 99 M. Friedman, Capitalism and Freedom (Chicago: The University of Chicago Press, 1962), p. 15. 100 PSP, p. 105.

286

Richard Titmuss

101 ‘Social Research and Social Policy’, unpublished talk at Balliol College, Oxford, n.d., circa 1960, in TP 3/370. 102 R.H. Tawney, ‘We Mean Freedom’ (1944), in his The Attack and Other Papers (London: George Allen and Unwin Ltd, 1953), p. 97. 103 R.M. Titmuss, F.J. Fisher and J.R. Williams, R.H. Tawney: A Portrait by Several Hands (London: privately published and printed by the Shenval Press, 1960), pp. 28, 33. 104 M. Weber, ‘Bureaucracy’, in H.H. Gerth and C.W. Mills, eds, From Max Weber: Essays in Sociology (London: Routledge and Kegan Paul, 1948), p. 228. 105 A. Downs, Inside Bureaucracy (Boston: Little, Brown and Company, 1967), p. 111. 106 EWS, p. 29. 107 EWS, p. 33. 108 ‘Some Problems in the Application of Sociological Knowledge to Social Welfare Research’, unpublished lecture, n.d., probably early 1960s, in TP 3/370. 109 Ibid. 110 Ibid.

5. Stigma 1 CW, pp. 20, 64; SP, p. 58. 2 E. Goffman, Stigma: Notes on the Management of Spoiled Identity (Englewood Cliffs, NJ: Prentice-Hall, 1963). 3 SP, p. 44. 4 CW, p. 26. 5 CW, p. 86. 6 CW, pp. 89, 98–9. 7 IS, p. 236. 8 Introduction to Equality, p. 16. 9 CW, p. 155. 10 CW, p. 134. 11 CW, p. 134. 12 CW, p. 163. 13 CW, p. 129. 14 CW, p. 119. 15 CW, p. 163. 16 CW, p. 132. 17 CW, p. 119. 18 CW, p. 121. 19 CW, p. 120. 20 CW, p. 120. 21 CW, p. 134. 22 CW, p. 143. 23 CW, p. 143. 24 CW, p. 113. 25 SP, p. 46.

Notes

287

6. Part Two: Evaluations and Extensions 1 2 3 4 5 6 7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23

‘The Irresponsible Society: Re-Assessment’, op. cit. Ibid. ‘The Social Services’, op. cit. Ibid. Ibid. Townsend, ‘Politics and Social Policy: An Interview’, loc. cit., p. 106. A. Davis, ‘Hazardous Lives–Social Work in the 1980s’, in M. Loney and others, eds, The State or the Market, 2nd edn (London: Sage, 1991), p. 88. Ibid. R. Pinker, Social Theory and Social Policy (London: Heinemann, 1971), pp. 141–2. See also Titmuss’s comment in SP, pp. 45–6. Beveridge, Social Insurance and Allied Services, op. cit., p. 108. Ibid. R.M. Titmuss, ‘Superannuation for All: A Broader View’, New Society, 27 February 1969, p. 315. C.A.R. Crosland, ‘Housing and Equality’, The Guardian, 15 June 1971, in his Socialism Now, ed. by D. Leonard (London: Jonathan Cape, 1974), p. 129. Ibid. S.M. Miller, ‘Introduction: The Legacy of Richard Titmuss’, in Abel-Smith and K. Titmuss, The Philosophy of Welfare, op. cit., p. 13. ‘Equality and Community’, op. cit. ‘English Society To-day and Tomorrow’, op. cit. ‘Equality and Community’, op. cit. T.R. Malthus, An Essay on the Principle of Population (1798), ed. by A. Flew (Harmondsworth: Penguin Books, 1970), p. 203. A. Marshall, ‘Social Possibilities of Economic Chivalry’ (1907), in A.C. Pigou, ed., Memorials of Alfred Marshall (London: Macmillan, 1925), p. 345. A. Marshall, Principles of Economics, 8th edn (1920) (London: Macmillan, 1949), p. 188. A. Marshall, ‘Where to House the London Poor’ (1884), in Pigou, Memorials, op. cit., p. 151. The Poor Law Report, in S.G. Checkland and E.O.A. Checkland, eds, The Poor Law Report of 1834 (Harmondsworth: Penguin Books, 1974), p. 36.

7. Universalism I: Social Costs and Social Benefits 1 2 3 4 5 6 7 8

SP, p. 67. CW, p. 63. CW, p. 156. EWS, p. 112. EWS, p. 112. EWS, p. 108. EWS, p. 109. PSP, pp. 216–17.

288 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Richard Titmuss PSP, p. 335. CW, p. 157. CW, p. 133. CW, p. 133. SP, p. 89. CW, p. 133. PSP, p. 382. SP, p. 133. SP, p. 133. CW, p. 163. CW, p. 164. CW, p. 157. CW, p. 158. CW, p. 63. CW, p. 134. CW, p. 133. SP, pp. 75–6. SP, p. 84. GR, p. 36. SP, p. 83. ‘Goals of Today’s Welfare State’, p. 355. EWS, pp. 8–9. SPPGM, p. 228. SP, p. 65. SP, p. 65. SP, pp. 65–6. SP, p. 67.

8. Universalism II: Integration and Involvement 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

SP, p. 38. CW, p. 131. CW, p. 22. HST, p. 171. PSP, p. 347. SP, p. 141. HST, p. 214. CW, p. 182. SP, p. 38. CW, p. 191. IS, p. 218. SP, p. 38. CW, p. 142. CW, p. 195. CW, p. 196. EWS, p. 37. SP, p. 14. CW, p. 66.

Notes 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

45 46 47 48 49 50 51 52 53

CW, p. 45. EWS, p. 74. CW, p. 71. R.M. Titmuss, ‘Welfare “Rights”, Law and Discretion’, The Political Quarterly, Vol. 411, 1971, p. 116. Ibid., p. 126. Ibid., pp. 124–5. Ibid., p. 127. Ibid., p. 116. CW, p. 22. GR, p. 13. GR, p. 12. GR, p. 245. GR, p. 177. GR, p. 198. GR, pp. 129–30. GR, p. 129. GR, p. 132. GR, p. 236. GR, p. 238. GR, p. 225. GR, p. 238. GR, p. 198. GR, p. 13. GR, p. 11. GR, p. 151. See M. Mauss, The Gift (London: Cohen and West, 1954), and C. LéviStrauss, The Elementary Structures of Kinship (London: Eyre and Spottiswoode, 1969). GR, p. 72. GR, p. 239. GR, p. 239. GR, p. 212. GR, pp. 213–14. GR, p. 214. GR, p. 214. GR, p. 215. GR, p. 159.

9. Universalism III: Planned Redistribution 1 2 3 4 5 6 7

289

CW, p. 189. CW, p. 65. ‘Goals of Today’s Welfare State’, p. 360. CW, p. 162. CW, pp. 193–4. IDSC, p. 79. The figures refer to 1959. IDSC, p. 89.

290 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

Richard Titmuss IDSC, p. 188. IDSC, p. 198. ‘Goals of Today’s Welfare State’, p. CW, pp. 32–3. CW, p. 32. ‘Goals of Today’s Welfare State’, p. Introduction to Equality, p. 12. ‘Goals of Today’s Welfare State’, p. Ibid., p. 363. CW, p. 196. EWS, pp. 208–9. GR, p. 136. CW, p. 67. IS, p. 230. EWS, p. 51. IS, p. 230. EWS, p. 73. SPPGM, p. 6. CW, p. 192. EWS, p. 55. CW, p. 197. CW, p. 135. Introduction to Equality, p. 9. CW, p. 164. Introduction to Equality, pp. 9–10. PSP, p. 348. PSP, p. 346. CW, p. 114. ‘Goals of Today’s Welfare State’, p. CW, p. 92. CW, p. 182. CW, p. 135. CW, p. 135. CW, p. 159. CW, p. 121. IDSC, p. 197. CW, p. 114. CW, p. 184. CW, p. 122. CW, p. 184. CW, pp. 121–2. CW, p. 114. CW, p. 135. CW, p. 114. CW, p. 33. CW, p. 34. CW, p. 34. CW, p. 34. CW, p. 34.

360.

359. 360.

365.

Notes 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74

291

Introduction to Equality, pp. 22–3. Ibid., p. 24. SP, p. 104. SP, p. 106. SP, p. 103. SPPGM, p. 110. ‘Superannuation for All: A Broader View’, p. 316. Ibid. EWS, p. 94. SPPGM, p. 100. SPPGM, p. 140. ‘Goals of Today’s Welfare State’, p. 362. Introduction to Equality, pp. 11–12. EWS, p. 105. SP, p. 25. SP, p. 25. EWS, p. 20. SP, pp. 24–5.

10. Part Three: Evaluations and Extensions 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

16 17 18 19

‘Equality – Britain and the U.S.A.’, op. cit. SP, p. 31. ‘Equality – Britain and the U.S.A.’, op. cit. A.C. Pigou, The Economics of Welfare (1920), 4th edn (London, Macmillan, 1932), p. 191. ‘The Evolution of Social Policy’, unpublished lecture at the Civil Service College, London, 23 November 1970, in TP 3/370. A. Deacon, ‘Richard Titmuss: 20 Years On’, Journal of Social Policy, Vol. 22, 1993, p. 236. Ibid., p. 237. Ibid., p. 239. ‘Trends in Social Policy Since 1948’, op. cit. Emphasis added. K.R. Hoover and R. Plant, Conservative Capitalism in Britain and the United States (London: Routledge, 1989), p. 221. Emphasis added. ‘The Family as a Social Institution’, op. cit. ‘Health as an Element in Welfare’, unpublished lecture to a UNESCO Anglo-Polish Seminar, n.d., probably 1950s, in TP 3/370. ‘The Family as a Social Institution’, op. cit. SP, p. 89. ‘The Right to Social Security’, unpublished lecture to a conference organised by the Child Poverty Action Group, 2 December 1967, in TP 3/370. SPPGM, p. 105. CW, pp. 63, 118, 131. ‘English Society To-day and Tomorrow’, op. cit. R.M. Titmuss, ‘Developing Social Policy in Conditions of Rapid Change: the Role of Social Welfare’, paper to the XVIth International Conference

292

20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

46 47 48 49

50 51 52 53

Richard Titmuss on Social Welfare, The Hague, 13 August 1972, in Abel-Smith and K. Titmuss, The Philosophy of Welfare, op. cit., p. 257. R.M. Titmuss, ‘The Welfare State: Images and Realities’, in C.I. Schottland, ed., The Welfare State (New York: Harper Torchbooks, 1967), p. 100. Ibid. Introduction to Equality, p. 13. ‘The Social Services’, op. cit. SP, p. 133. EWS, p. 109. EWS, p. 109. EWS, p. 116. EWS, pp. 117–18. G. Myrdal, ‘The Place of Values in Social Policy’, Journal of Social Policy, Vol. 1, 1972, pp. 6–7. ‘Equality and Community’, op. cit. J.K. Galbraith, The Affluent Society (1958) (Harmondsworth: Penguin Books, 1973), p. 212. J.K. Galbraith, A View from the Stands (Boston: Houghton Mifflin, 1986), p. 5. EWS, p. 181. EWS, p. 182. EWS, p. 198. EWS, p. 198. Miller, ‘Introduction’, in Abel-Smith and K. Titmuss, The Philosophy of Welfare, op. cit., p. 4. T.H. Marshall, Sociology at the Crossroads and Other Essays (London: Heinemann, 1963), p. 246. Marshall, The Right to Welfare, op. cit., p. 91. Ibid., p. 109. EWS, p. 107. Emphasis added. A. Oakley and J. Ashton, ‘Introduction to the New Edition’, in R.M. Titmuss, The Gift Relationship (New York: The New Press, 1997), p. 7. Cited in ibid. GR, p. 159. M.H. Cooper and A.J. Culyer, ‘The Economics of Giving and Selling Blood’, in A.A. Alchian and others, The Economics of Charity (London: Institute of Economic Affairs, 1973), p. 134. GR, p. 89. ‘The Meaning of Poverty’, unpublished lecture notes, Queen Elizabeth College, 8 December 1970, in TP 3/370. SPPGM, pp. 93–4. See on this G. Weaver and A.S. Williams, ‘A Mother’s Gift: The Milk of Human Kindness’, in Titmuss, The Gift Relationship, 1997 edn, op. cit., Ch. 18. CW, p. 191. GR, p. 199. Cooper and Culyer, ‘The Economics of Giving and Selling Blood’, op. cit., p. 134. ‘The British Health Service and Professional Freedom’, unpublished

Notes

293

lecture at Seattle University, n.d., probably 1967, in TP 3/370. 54 GR, p. 198. 55 P. Kropotkin, Mutual Aid (London: William Heinemann, 1902), pp. 15, 57. 56 Cooper and Culyer, ‘The Economics of Giving and Selling Blood’, op. cit., p. 113. 57 GR, p. 16. 58 H. Hansmann, ‘The Economics and Ethics of Markets for Human Organs’, Journal of Health Politics, Policy and Law, Vol. 14, 1989, p. 73. 59 A. Smith, The Wealth of Nations (1776), ed. by E. Cannan (London: Methuen, 1961), Vol. I, p. 18. 60 CW, p. 150. 61 R.D. Roberts and M.J. Wolkoff, ‘Improving the Quality and Quantity of Whole Blood Supply: Limits to Voluntary Arrangements’, Journal of Health Politics, Policy and Law, Vol. 13, 1988, p. 177. 62 GR, p. 292. 63 GR, p. 289. 64 GR, p. 239. 65 K.J. Arrow, ‘Gifts and Exchanges’, Philosophy and Public Affairs, Vol. 1, 1972, p. 350. 66 P. Singer, ‘Altruism and Commerce: A Defense of Titmuss against Arrow’, Philosophy and Public Affairs, Vol. 2, 1973, p. 315. 67 B. Disraeli, Sybil or The Two Nations (1845) (London: Peter Davies, 1927), pp. 75–6. 68 A. Marshall, ‘The Future of the Working Classes (1873), in Pigou, Memorials of Alfred Marshall, op. cit., p. 102. This is the passage which so much excited T.H. Marshall when he was preparing the two Alfred Marshall lectures he gave at Cambridge in February 1949. Those lectures were later published in his influential Citizenship and Social Class (Cambridge: Cambridge University Press, 1950). 69 Tawney, Equality, op. cit., p. 49. 70 ‘The Right to Social Security’, op. cit. 71 ‘Health as an Element in Welfare’, op. cit. 72 ‘The Right to Social Security’, op. cit. 73 ‘Trends in Social Policy Since 1948’, op. cit. 74 R.A. Nisbet, The Sociological Tradition (London: Heinemann, 1967), p. 47. 75 HST, p. 214. 76 P. Marris and P. Rein, Dilemma of Social Reform (Harmondsworth: Penguin Books, 1974), p. 101. 77 ‘Goals of Today’s Welfare State’, p. 359. 78 EWS, p. 74. 79 The Social Services – Present and Future’, unpublished lecture, n.d., possibly 1968, in TP 3/370. 80 ‘Trends in Social Policy since 1948’, op. cit. 81 Ibid. 82 ‘Pensions and Social Policy’, unpublished lecture, n.d., circa 1958, in TP 3/370. 83 C.A.R. Crosland, The Future of Socialism (1956) (London: Cape, 1964), p. 148.

294

Richard Titmuss

84 J. Le Grand, The Strategy of Equality (London: George Allen and Unwin, 1982), pp. 3–4. 85 ‘The Meaning of Poverty’, op. cit. 86 Ibid. 87 ‘Poverty in the 1960s’, unpublished lecture, n.d., in TP 3/370. 88 ‘The Evolution of Social Policy’, op. cit. 89 R.M. Titmuss, ‘A Commentary’, in W.J. Braithwaite, Lloyd George’s Ambulance Wagon (London: Methuen, 1957), p. 56. 90 Galbraith, The Affluent Society, op. cit., p. 259. 91 ‘Trends in Social Policy since 1948’, op. cit. 92 ‘Poverty in the 1960s’, op. cit. 93 Ibid. 94 EWS, p. 39. 95 Beveridge, Full Employment in a Free Society, op. cit., p. 17. 96 ‘The Meaning of Poverty’, op. cit. 97 ‘Developing Social Policy in Conditions of Rapid Change’, pp. 254, 255. 98 Ibid., p. 255. 99 ‘The Growth of Social Policy’, op. cit. 100 ‘Developing Social Policy in Conditions of Rapid Change’, p. 258. 101 PP, p. xvii. 102 ‘The Family in the Welfare State’, unpublished paper, 1952, in TP 3/371. 103 Ibid. 104 Wilding, ‘Titmuss’, op. cit., p. 155. 105 EWS, p. 39. 106 ‘The Social Services’, op. cit. 107 ‘Social Research and Social Policy’, op. cit. 108 Marshall, The Right to Welfare, op. cit., p. 104. 109 Ibid., p. 109. 110 EWS, pp. 8–9. 111 ‘Social Needs and Social Policy’, unpublished conference paper dated 3 January 1953, in TP 3/374. 112 ‘The Social Services’, op. cit. 113 ‘Social Needs and Social Policy’, op. cit. 114 ‘The Social Services’, op. cit. 115 ‘Social Needs and Social Policy’, op. cit. 116 GR, p. 241. 117 ‘Equality – Britain and the U.S.A.’, op. cit. 118 ‘The Irresponsible Society: Re-Assessment’, op. cit. 119 ‘The Social Services’, op. cit. 120 ‘Social Needs and Social Policy’, op. cit. 121 Ibid. 122 Ibid. 123 Ibid. 124 Ibid. 125 Ibid. 126 Ibid. 127 ‘The Social Division of Welfare’, op. cit.

Notes 128 129 130 131 132 133 134 135 136

295

‘The Family in the Welfare State’, op. cit. ‘The Evolution of Social Policy’, op. cit. PSP, p. 46. ‘The Evolution of Social Policy’, op. cit. Beveridge, Social Insurance and Allied Services, op. cit., p. 170. Rose, ‘Rereading Titmuss’, loc.cit., p. 488. Ibid., p. 491. ‘The Evolution of Social Policy’, op. cit. A. Oakley, letter to D.A. Reisman dated 25 June 1980, in D.A. Reisman, State and Welfare (London: Macmillan, 1982), p. 81. 137 Cited in ibid. 138 Pinker, Preface to Reisman, Richard Titmuss, op. cit., p. viii. 139 Ibid.

11. The Failure of the Market I: Quality 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

GR, p. 95. CW, pp. 134–5. GR, p. 147. GR, p. 146. GR, p. 144. GR, p. 240. GR, p. 240. CW, p. 151. GR, p. 95. GR, p. 149. GR, p. 154. GR, pp. 154–5. GR, p. 246. GR, p. 157. CW, pp. 224–5. SPPGM, p. 35; CW, pp. 226, 253. CW, p. 257. CW, p. 257. SPPGM, p. 177. CW, p. 250. CW, p. 254. CW, p. 255. CW, p. 254. CW, p. 222. GR, p. 166. GR, p. 166. CW, p. 254. CW, p. 254. GR, p. 166. CW, p. 260. CW, p. 208. SP, p. 56.

296 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57

Richard Titmuss SP, p. 56. SPPGM, p. 196. HST, p. 212. See also EWS, pp. 159, 161, 189. GR, p. 170. GR, p. 170. HST, p. 69. HST, p. 101. EWS, p. 200. HST, p. 69. CW, p. 225. CW, p. 225. CW, p. 208. CW, p. 255. EWS, pp. 124–5. EWS, p. 126. CW, p. 210. CW, p. 73. CW, pp. 73–4. CW, p. 250. CW, p. 71. CW, p. 70. CW, p. 213. CW, p. 208. EWS, p. 193. EWS, p. 191.

12. The Failure of the Market II: Choice 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

CW, p. 91. SP, p. 55. CW, pp. 67–8. CW, p. 184. IS, p. 238. IS, p. 240. IS, p. 236. SP, p. 112. CW, p. 178. CW, p. 179. CW, p. 183. CW, p. 180. CW, p. 179. SP, p. 92. SP, p. 98. CW, p. 193. CW, p. 181. IS, p. 241. ‘A Commentary’, in Braithwaite, Lloyd George’s Ambulance Wagon, op. cit., p. 53.

Notes 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

EWS, p. 28. IS, p. 216. EWS, p. 121. CW, p. 196. EWS, p. 155. EWS, p. 197. EWS, p. 196. EWS, p. 197. CW, p. 212. CW, p. 184. HST, pp. 202–3. EWS, pp. 119, 120. SP, p. 14. ‘The Social Services – Present and Future’, op. cit. SP, p. 42. See also pp. 34, 130. CW, p. 196. EWS, p. 27. EWS, p. 27. ‘Goals of Today’s Welfare State’, p. 364. EWS, p. 190. EWS, p. 128. EWS, p. 183. EWS, p. 130. HST, p. 145. HST, p. 146. HST, p. 146. HST, p. 101.

13. The Failure of the Market III: Quantity 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

CW, p. 252. CW, p. 253. CW, p. 254. GR, p. 220. CW, p. 254. CW, p. 254. CW, p. 268. PSP, pp. 70–1. PSP, p. 71. CW, p. 254. HST, p. 102. HST, p. 111. HST, p. 110. HST, p. 100. HST, p. 215. CW, p. 149. GR, p. 196. CW, p. 150.

297

298 19 20 21 22 23 24

Richard Titmuss GR, p. 32. GR, p. 44. GR, p. 207. IS, p. 229. Introduction to Equality, p. 9. CW, p. 76.

14. The Failure of the Market IV: Price 1 2 3 4 5 6 7 8 9 10 11 12 13 14

CW, p. 252. CW, p. 254. CW, p. 253. CW, p. 151. CW, p. 258. SP, p. 82. CW, p. 122. GR, p. 205. GR, p. 196. GR, p. 49. GR, p. 57. GR, p. 63. CW, p. 252. CW, p. 255.

15. Part Four: Evaluations and Extensions 1 Pinker, Preface to Reisman, Richard Titmuss, op. cit., p. x. 2 R. Pinker, The Idea of Welfare (London: Heinemann Educational Books, 1979), p. 248. 3 Ibid., p. 53. 4 Ibid., p. 51. 5 HST, p. 99. 6 HST, p. 165. 7 HST, p. 166. 8 HST, p. 159. 9 Cost, p. 59. 10 ‘The Irresponsible Society: Re-Assessment’, op. cit. 11 ‘Social Policy and Social Work Education’, unpublished lecture given in New York, March 1957, in TP 3/373. 12 CW, p. 138. 13 CW, p. 20. 14 EWS, p. 126. 15 Wilding, ‘Titmuss’, op. cit., p. 155. 16 CW, p. 266. 17 SP, p. 82. 18 C. Pierson, Beyond the Welfare State?, 2nd edn (Cambridge: Polity Press, 1998), p. 26. 19 ‘Social Needs and Costs’, op. cit.

Notes

299

20 Introduction to Equality, p. 10. 21 ‘Social Policy in an Ageing Society’, unpublished lecture given at Cambridge, n.d., probably 1950s, in TP 3/369. 22 Ibid. 23 ‘Social Needs and Costs’, op. cit. 24 ‘Social Policy in an Ageing Society’, op. cit. 25 Ibid. 26 Ibid. 27 Pierson, Beyond the Welfare State?, op. cit., p. 3. 28 Tawney, Equality, op. cit., p. 81. 29 Ibid., p. 40. 30 R.M. Titmuss, ‘Social Welfare and the Art of Giving’, in E. Fromm, ed., Socialist Humanism (London: Allen Lane, 1967), pp. 358–9. 31 ‘The Growth of Social Policy’, op. cit. 32 ‘The Social Division of Welfare’, op. cit. 33 CW, p. 22. 34 SP, p. 29. 35 Marshall, The Right to Welfare, op. cit., pp. 124–5. 36 Ibid., p. 117. 37 R. Pinker, ‘T.H. Marshall’, in George and Page, Modern Thinkers on Welfare, op. cit., p. 107. 38 Pinker, The Idea of Welfare, op. cit., p. 245. 39 Ibid., p. 233. 40 Pinker, Preface to Reisman, Richard Titmuss, op. cit., p. ix. 41 Ibid., pp. ix–x. 42 ‘Social Policy in an Ageing Society’, op. cit. 43 Titmuss provides an account of this episode in CW, pp. 263–4. 44 Letter from R.M. Titmuss to R.H.S. Crossman dated 25 November 1963, in TP 2/182. 45 Letter from R.M. Titmuss to S.M. Miller dated 11 May 1967, in TP 2/182. 46 Letter from Colin Clark to R.M. Titmuss dated 14 April 1964, in TP 2/182. 47 Letter from R.M. Titmuss to M. Lasky dated 27 November 1967, in TP 2/182.

16. Conclusion 1 IS, p. 215. 2 See on this M.A. Salo, Titmuss, Mauritius and the Social Population Policy: A Methodological Study (Turku: Turun Yliopisto, 1982). 3 R.M. Titmuss, Foreword to M. Rein, Social Policy (New York: Random House, 1970), p. v. 4 R.M. Titmuss, ‘Historical Sedatives’, New Statesman, 16 June 1961, p. 962.

300

Index

Index Brown, George, 249 Buchanan, J.M., 74, 75, 82 bureaucracy, 84, 86, 87, 104, 238 business executives, 219

Abel-Smith, B., 2, 4, 23, 24, 274 abuse of power, 128–9 abuse of welfare services, 93, 109, 164 accidents, 114, 120, 121 Acland, Sir Richard, 12 AIDS, 204 alienation, 168–9 altruism, 129, 130, 132, 134, 178, 262 see also donation; free gifts; voluntarism apprenticeship, 63 Arkwright, R., 167 Arrow, K., 180, 181, 206 Ashton, J., 174 Attlee, Clement R., 1 autonomy, 85 banking sector, 55 bankruptcy, 120 Barnett, Samuel, 187 Bell, Daniel, 35 benefits, 142, 159, 185, 214 Bentham, Jeremy, 168 Bevan, Aneurin, 1, 81, 245 Beveridge Report (1942), 102, 103 Beveridge, W.H., 9, 58, 59, 65, 197, 264 birth-control, 13, 15, 37, 38 Birth, Poverty and Wealth, 3, 17, 18 birth-rate, 12, 14, 37 Blackburn, Robin, 24 black immigrants, 30, 79, 170 blood, 175, 203–6, 234–6, 239–40 blood-donorship, 35, 131–3, 176–9, 205; paid, 40, 203–4, 205, 239; in Soviet Union, 176, 177; studies, 129, 130; see also under United States of America Boer War, 32, 195 Booth, Charles, 187, 195, 272 Brotherston, J.H.F., 223

capitalism, 14, 16, 41 car industry, 165 Carr-Saunders, Sir Alexander, 22 Castle, Barbara, 81 Caston, Richard see Titmuss, Richard Morris causality, 116, 119, 121, 161 social, 170, 171–2, 192 centralised power, 82 charities, 175 Charles, Enid, 12 chemical industry, 121–2 children, 115, 116 choice, 36, 127, 217–29, 246–53 moral, 133, 159, 194 Churchill, Sir Winston, 196 civil servants, 84, 87, 229 Clark, Colin, 266 Clark, F. Le Gros, 3, 10, 11 Cohen, Wilbur, 25 Commitment to Welfare, 4 community, 123–4, 129, 130, 135, 149, 181–9 defined, 183 compensation, 118, 119–20, 158, 160, 171 competition, 86, 246, 252 competitive market, 107–8, 246 complementarity, 165, 256, 257, 259 confidence, 191 consensus, 76, 80, 171, 200, 242, 269 consumers, 78, 205, 206, 208, 224 Cooper, M., 174, 177, 178 costs, 138, 142, 150, 151 social costs and social benefits, 113–22, 158, 160–1, 170, 214

300

Index council housing, 104 County Fire Insurance Office, 5, 16, 19 covenants, 139, 141 credentialism, 47, 144 crime, 167–8 Crime and Tragedy, 8 Crompton, Samuel, 167 Crosland, C.A.R. (Anthony), 81, 104, 105, 186, 253, 265 Crossman, R.H.S., 25, 266 Culyer, A., 174, 177, 178 Davis, A., 101 Deacon, A., 161, 162 defence expenditure, 259 demand and supply, 80, 246, 261 democratic persuasion, 83 demography, 17 dependency, 30, 100–1, 108, 145, 162 devolution, 82 diphtheria, 10, 12, 34 directors, 219 discretionary system, 129 discrimination, 85, 91, 106, 125, 155 selective, 85, 148, 151, 155, 168, 186 Disraeli, Benjamin, 181, 198 diswelfare, 119, 159 division of labour, 6, 228 doctors, 206, 208, 211, 229, 230 doctor-patient relationship, 208–9, 239 general practitioners, 212–16, 231, 240 donation, 159 organ, 175, 178, 264 see also altruism; blood; free gifts; voluntarism Donnison, D., 1, 24 Downs, A., 81, 82, 83, 84 Doyal, L., 73 Dunkirk, 33, 196 Durkheim, Émile, 273, 274, 275 economic criteria, 157 economic externalities, 159–74

301

economic market, 78, 242, 243 economic power, 82 economics, 241, 242, 246–7, 258, 269 macroeconomic welfare, 57–8, 59, 60, 68, 260 microeconomic welfare, 60–4, 67, 68, 160, 260 economies of scale, 80, 219 economists, 257, 265 economy, 61, 82, 115, 206 mixed economy, 82, 99, 162, 261 education, 105, 114, 142–3, 155, 184 educational second chances, 186 educative role of social worker, 127 11-plus examination, 105 higher, 139, 152 private sector, 153 Eleanor Rathbone Memorial Lecture (1955), 2 employment, full, 58, 59–60, 70, 140 Engels, F., 82 equality, 31, 55, 84, 148, 159 achieving, 186–7 of opportunity, 63, 184 of treatment, 126 equal opportunities, 63, 184 ethnic minorities, 77, 125, 251 eugenics, 8, 9, 13, 17 Eugenics Society, 8, 18, 19, 22 experience-rating, 220 experts, 68, 226–8 externalities, 159–74 factory accidents, 114, 121 family, 15, 68–9, 114 women, status of, 69–71 family allowances, 38 family doctors see doctors; general practitioners family planning see birth-control firm, the, 165–7, 170 fiscal welfare, 57, 63, 68, 138, 139 flat rate contributions, 150 France, 12 freedom of the press, 226

302

Index

free enterprise, 242 free gifts, 132, 134, 135–6, 173, 177 beneficiaries of, 164 see also altruism; donation; voluntarism free-market economy, 206 Freud, Sigmund, 32, 75, 168 Friedman, M., 82, 226, 265 friendly societies, 65, 195 fringe benefits see occupational welfare

Hill, Octavia, 195 Hitler, Adolf, 8 Hoover, K.R., 162 Horder, Lord John, 9, 68 horizontal differentiation, 76 hospitals, 134, 213–14, 223–4, 230–1, 237, 249 Hubback, Eva, 19 Huddleston, Rt Revd Trevor, 25, 199 human contact, 129 humanism, 43, 44–5

Galbraith, J.K., 83, 170, 188, 191, 256, 265 Galton, F., 8, 10 Geddes, Sir Eric, 2 generalism, 43–4 general practitioners, 212–16, 231, 240 see also doctors genetic inheritance, 8 Germany, 8, 12, 16–17, 275 Gift Relationship, The, 2, 16, 174, 181, 198, 272 Glass, David, 9, 12 Goffman, E., 91 Good Society, 182, 183 Gorky, Maxim, 8 Gough, I., 73 Gowing, M., 6, 25 graduated contributions, 186 Gresham’s Law (Sir Thomas Gresham), 118 Greve, John, 24 group risk-rating, 219–20 growth, 55, 85, 97, 148, 253–61 Grundy, Dr Fred, 3, 21

ideology, 35–6 illfare, 163 Illich, I., 68 Income Distribution and Social Change, 248, 271–2 income maintenance, 185 income tax see taxes indirect taxation, 160 individualism, 15, 161–5, 170, 172, 246, 250 Disraeli on, 181 metaphysical, 156 unacceptability of, 41 individual risk-rating, 219–20 industrial disease, 114 industrialisation, 114–15, 182–3, 192 Industrial Revolution, 193 inequality, 140–3 inflation, 172 Institute of Economic Affairs, 174, 265, 266 insurance, 55, 56, 209, 211, 239 medical, 209, 238, 252 private, 56, 92, 218–22 integration, 79, 123–36, 158, 185, 261 interventionism, 65, 162 involvement and universalism, 123–36 Irresponsible Society, The, 270 Israel, 54

haemophilia, 132, 236 Hancock, Sir W. Keith, 19, 20, 22 handmaiden function, 121, 161, 165, 167, 173 Hansmann, H., 178 Harris, Ralph, 265 health and safety, 63 health service contributions, 150 hepatitis, 204 higher education, 139, 152

Japan, 35, 235, 240 Jewkes, J., 266 job satisfaction, 85 Joseph, Sir Keith, 25

Index Kemp, A., 266 Keynes, J.M., 7, 58, 59, 80, 191, 264 Kropotkin, P., 177, 178 Lasky, Melvin, 266 Lees, D.S., 265, 266 legislation, 252 legitimation, 159, 189–200 Le Grand, J., 186 liberal utilitarianism, 275 London School of Economics, 22–3, 24 lower class, 79 Lynes, Tony, 2 Lévi-Strauss, C., 133 Macdonald, George, 2 Macmillan, Harold, 7, 9, 265 macroeconomic welfare, 57–8, 59, 60, 68, 260 malpractice, 208–9, 211 Malthus, T.R., 107 Marcuse, Herbert, 226 market, 41, 99–100, 235, 242, 261 competitive, 107–8, 246 economic, 78, 242, 243 economy, 82 failure, 157, 203–40, 269 free-market economy, 206 political, 81–2 Marris, P., 184 Marshall, A., 108, 177, 181 Marshall, T.H., 61, 80, 173, 191, 263 and London School of Economics, 22, 23 Marxism, 275–6 Marx, K., 32, 62, 82 maternal death-rate, 10 Mauritius, 37, 39, 74, 121, 154, 155 and health care, 207, 210 population, 271 Mauss, M., 133 means test, 25, 93–5, 104, 108, 269 and stigma, 93, 117 mechanistic methodology, 51 media, 104, 126, 208, 225

303

medical care, 174, 209, 217, 222–5, 229 medical consultation rates, 144 medical insurance, 209, 238, 252 medical professionals, 210, 226–8 metaphysical individualism, 156 methodology, 43–51, 269 microeconomic welfare, 60–4, 67, 68, 160, 260 microsociological objectives, 85 middle class, 32, 78, 126, 142, 144, 222 professionals from, 227–8 Miller, Kathleen (Kay) see Titmuss, Kay Miller, S.M., 104, 172, 266 Mill, J.S., 64 Mishra, R., 4 mixed economy, 82, 99, 162, 261 moral choice, 133, 159, 194 moral schizophrenia, 261–2 Morris, J.N., 18, 21 Morris, William, 198 mortality, 10, 17–18, 144 Myrdal, Alva and Gunnar, 12 Myrdal, Gunnar, 78, 169 National Blood Transfusion Service, 131, 132 National Health Service, 31, 34, 54, 55, 99, 125–6, 132, 183, 184, 194, 209, 270 cost of, 259 purpose of, 214 quality of treatment in, 96, 126, 222 shortages within, 231 national insurance contributions, 150 nationalisation, 55, 169 nationalism, 183, 198 national minimum wage, 63 National Superannuation Bill (1970), 24, 42, 153–5, 185 needs, 30, 43, 72–5, 127, 128 categories, 151 Titmuss’s interpretation of, 193, 194 negative income tax, 94, 128

304

Index

neighbourhood effects, 159, 194 Nevitt, Della, 24 Nightingale, Florence, 195 Nisbet, R., 183 noblesse oblige, 195 non-judgementalism, 79 nutrition, 10, 11, 17 Nyerere, Julius, 25 Oakley, Ann (daughter of RMT), 5, 6, 23, 70 on The Gift Relationship, 174 on Titmuss, 1, 22, 23, 199 occupational welfare, 57, 63, 68, 145–7 O’Connor, J., 81 oligopoly, 219 organ donorship, 175, 178, 264 organisational goals, 85 Our Food Problem, 3, 10–11, 12 owner-occupiers, 104 Parents Revolt, 3, 12–16 Parker, Roy, 24 Parsons, Talcott, 156 patriotism, 198 peasantry, 192 pensions, 153, 155, 185, 218 private schemes, 138, 219, 221 and women, 154–5 personal contact, 129 personal responsibility, 161–2, 172 pharmaceutical industry, 55 pharmacists, 207 philanthropy, 198 Pierson, C., 252, 256 Pigou, A.C., 61, 159, 160, 171 Pinker, R., 101–2, 103, 199, 264 on Problems of Social Policy, 2 on Tawney and Titmuss, 199 on T.H. Marshall, 263 on Titmuss, 1, 24, 242, 263, 264 Plant, R., 162, 265, 266 plasma, 205 political market, 81–2 political power, 82, 83 politicians, 81, 82, 84, 229 Poor Law Report (1834), 108 population, 9, 12–13, 14, 271

positive discrimination, 106, 155 poverty, 10, 17, 118, 161, 187–8 Poverty and Population, 3, 8, 9, 10, 12 power-sharing, 78 pressure groups, 79–80 prevention, 171, 172 preventive medicine, 215 price, 61, 62, 237–40, 248 private education, 153 private enterprise, 91, 165, 169 private hospitals, USA, 237 private insurance, 56, 92, 218–22 private medicine, 55, 96, 259 private pensions, 138, 219, 221 private treatment, 92, 252 privatisation, 39, 82, 86, 103, 180 Problems of Social Policy, 2, 3, 20, 198 professional practice see doctors professionals, 44, 86, 210, 226–8 progressive taxes, 257–8 property, inherited, 141 property speculation, 236 public schools, 55, 153, 197 public services, 96 quality of provision, 32, 96, 129, 203–16, 222 quantity of welfare services, 32, 230–6 racial discrimination, 106, 125 Radcliffe-Brown, A.R., 156 redistribution, 137–57 redundancy, 113, 141 Rein, P., 184 rejection, 107, 108 relevance, 43, 46–9 religion, 199 Report on Luton, 3, 21 research, 47, 87, 135, 208 resource allocation, 242 restitution, 118, 119–20, 158, 160, 171 rheumatic heart disease, 18 Richardson, Elliot, 272 ritual-exchange system, 133 road accidents, 120

Index Robbins, Lionel, 24, 265, 266 Roberts, R.D., 179 Rose, H., 3, 24, 68, 198 Rowntree, Seebohm, 188, 272 Russia, 35, 130, 177, 235 scarcity, 149, 243–6 scepticism, 43, 49–51 Scotland, 54 Second World War, 32, 34, 44 – 45, 115–16, 124, 196–7 security, 85 Seldon, Arthur, 174, 265, 266 selection, 100, 109 selective discrimination, 85, 148, 151, 155, 168, 186 selectivity, 91–7 self-discrimination, 91 self-esteem, 103, 185 self-interest, 65, 85 self-medication, 208 services in kind, 186 Shaftesbury, Anthony Ashley Cooper, 7th Earl of, 195 shame, 96, 133 Shaw, George Bernard, 8 Singer, P., 180, 181 Smith, Adam, 146, 179, 181, 265 social benefits, 35, 113–22, 158, 170, 217 social causality, 170, 171–2, 192 social class, 17, 131, 144 social costs, 113–22, 158, 160–1, 170 social deviation, 118 ‘Social Division of Welfare, The’, 2, 3 social involvement indicators, 175 social irresponsibility indicators, 175–6 socialism, 41, 83, 182, 199, 276 social market v economic market, 242 social matrix, 160, 167–70 social obligation, 170 social philosophy, 270–3 social policy, 29–42, 74, 160, 255, 269 social reformers, 195

305

social sanctions, 96, 133 social science, 270–3 social solidarity, 167, 194, 196 social theory, 273–6 social values, 191 social welfare, 63, 68, 96, 147–8, 163–4 social workers, 104, 127, 189 sociological economics, 241, 242 solidarity, 167, 194, 196 Soviet Union, 14, 176, 177 specialisation, 46–7 Spectator, The, 266 state insurance, 56 state intervention, 65 state medicine, 211, 215 state services, 55, 57, 93, 259 statistical tools, 44, 45 status, 37, 69–71, 114 stigmatisation, 93–5, 99–100, 101, 103–6, 109 avoidance of, 96–7 of general practitioners, 215 invisible, 92–3 and means test, 93, 117 and redistribution, 150 by Second World War, 116 self-stigmatisation, 91 stomach ulcers, 18 subsidies, 61–2, 70 Supplementary Benefits Commission, 25, 128–9 supply and demand, 80, 246, 261 Sweden, 169, 197, 235, 240 Tanganyika, 38, 74, 123, 210, 211–12, 223–4 health service, 229, 232–4 and scarcity, 243–4 Tawney, R.H., 61, 182, 191, 197, 199, 225, 258 Equality, 11, 16 on politicians, 84 on Problems of Social Policy (Titmuss), 20 Ratan Tata Lecture, 18 on the State, 81 taxes, 61–2, 138–41, 150–1, 186, 190, 257

306

Index

taxes – continued indirect, 160 negative, 94, 128 progressive, 257–8 teaching hospitals, 134 technology, 63, 113, 143, 144 Temple, W., 61 textbook economics, 246–7 theoretical analysis, 53 Times, The, 33 Titmuss, Kay (wife of RMT), 2, 3, 4, 5–6, 7, 12 Titmuss, Maude (mother of RMT), 5, 7 Titmuss, Morris (father of RMT), 5 Titmuss, Richard Morris, 1–26 background, 5 daughter, 6, 12 death, 3, 25 education, 5, 19, 21 employment, 5, 16, 19, 21 Fellowships, 19 government committees, 25 honorary doctorates, 23 and Institute of Economic Affairs, 265–6 literary style, 271 LSE appointment, 22 marriage, 6 his optimism, 190, 249 politics, 7, 16 publications, 2, 3, 8 religion, 199–200, 276 tolerance, 33 Townsend, P., 23, 24, 68, 100 trade unions, 79, 195, 255 unemployment, 9, 37, 113–14 United States of America, 35, 125, 130, 169, 237–40 blood banks, 272 and blood donorship, 176, 177, 179, 203, 205; inadequacy of transfusion, 234; paid donorship, 203, 204 doctor-patient relationships, 208–9, 239 general practitioners, 212, 240 medical services, 125

private enterprise, 169, 237 quantity of welfare services, 230 universalism, 103, 158, 159, 187, 214, 269 and growth, 97 and integration and involvement, 123–36 of National Health Service, 96 social costs and social benefits, 113–22, 158, 160–1, 170, 214 universal welfare, 156 universities, 46–7, 50, 142, 143, 152 upper class, 126, 142, 144 value-conflict, 75, 76, 77 value judgements, 50, 117–18 Vancouver Sun, 7 vertical differentiation, 75 voluntarism, 64–7, 79, 133, 175, 195 see also altruism; blood; donation; free gifts vouchers scheme, welfare, 250–2, 265 wants, 72–3, 189 war, 9, 32–3, 58, 124, 171, 196–7 Ward, Christopher, 2 Webb, Beatrice, 8, 14, 58, 80, 195 Webb, Sidney James, Baron Passfield, 8, 58, 80, 195 Weber, M., 84, 238, 273, 275 welfare, 72–87, 183, 261 fiscal, 57, 63, 68, 138, 139 macroeconomic, 57–8, 59, 60, 68, 260 market failure, 157, 203–40, 269 microeconomic, 60–4, 67, 68, 160, 260 occupational, 57, 63, 68, 145–7 quantity of, 32, 230–6 social, 63, 68, 96, 147–8, 163–4 state, 55, 57, 93, 259 sub-divisions of, 53–71 universal, 156 vouchers scheme, 250–2, 265 Welfare World, 156, 175

Index Whitehead, A.N., 213 Wilding, P., 3, 26, 249–50 Williams, Arthur, 2 Wilson, Harold, 23, 174 Wolkoff, M.J., 179

307

women, 6, 37, 39, 140, 152, 154–5 family status of, 69–71 working class, 45, 100, 143, 194–5 Workmen’s Compensation Insurance, 238