Introduction

This chapter begins with a brief analysis of the ‘changing work paradigm’ in globalised economies and the evidence for the impact of this on mental health outcomes, particularly in terms of those who are or may become ‘precariously distressed’ (Rogers and Pilgrim, 2003). This is followed by an account of structural stigma within mainstream mental health policies and the way in which they continue to reflect a risk agenda. The chapter then identifies the relationship between networks of risk in mental health and the networks of trust that have been negotiated between major constituencies, particularly between the state and relatives of victims of so-called ‘community care homicides’. The fourth and final section analyses in more depth the power of the lobby that broadly represents the latter group through the “organising power of grief “ (Peay, 1996, p 23, after Rock in the same volume). The chapter concludes by explicating the circular and paradoxical nature of current policies. It is argued that they are liable to fail, not only those citizens who require mainstream mental health services, but also the much larger number of people who, regardless of the reality of the risks, consider their lives and livelihoods as precarious and insecure.

During any single year, more than one in four adults in the European Union (EU) will experience some form of mental ill health, the most common forms being anxiety disorders and depression (European Commission, 2005). Suicide accounts for more deaths per annum in the EU than deaths from either homicide, HIV/AIDS or road traffic accidents (European Commission, 2005) and, while suicide statistics are notoriously problematic, the greater likelihood is that this is an under-rather than an over-estimate. In the UK in 2004, 5,906 people aged 15 years or older committed suicide (ONS, 2006). The economic and social costs associated with poor mental health are substantial and are rising throughout Europe, due largely to escalating levels of absenteeism from work (Mental Health Europe, 2002-04). While the severity of more common forms of mental distress such as depression and anxiety is sometimes minimised in comparison with psychotic illnesses such as schizophrenia, there is clear evidence that their impact on social functioning can be major and the economic costs substantial as a result (Glozier, 2002; Layard, 2006).

Introduction

Traditional approaches to migration theorising, particularly in a European context, have tended to focus rather narrowly on a limited number of economic determinants and, in particular, the effect of wage differentials in shaping migration and location decisions. The emphasis on the migration decision has also tended to characterise migration as a one-time event, perhaps followed by a return move. In recent years, research has drawn attention to the role that a much wider range of factors play in shaping what are now conceptualised more accurately as migration processes or, in a European context ‘mobilities’. This might include a more holistic appraisal of economic factors to encompass living costs and expenditures and their impact on family resources. In addition to this, research has encouraged us to consider the impact that personal and family relationships and obligations might have on migration behaviour, perhaps generating resistance to the ‘pull’ of economic considerations or, in other contexts, lubricating mobility. Concerns around spousal employment rights and the impact of dual career situations form the focus of an increasing body of research reflecting a move away from the individualistic and consensual ‘male breadwinner’ model towards acknowledging the role that couples play in migration decision making. Boyd critiques economic rationality models that “emphasise the movement of people as a result of rational calculations performed by individual actors”, drawing attention to the role of partners and wives in particular (1989, p 640). A necessary development to this has been research exploring the impact of migration on family life (Mincer, 1978; Litcher, 1980; Bailey and Cooke, 1998; Cooke, 2001; Ackers and Stalford, 2004; for a review of research in this area, see Kofman, 2004). Bailey and Boyle (2004), in their review of the multidisciplinary literature in this area, refer to the traditional assumption that migration decisions involving families are based on rational, economic logic. This implies a process by which the migrant worker parent (typically the male) weighs up the net economic gain to the family unit of moving. Similarly, Scott refers to the relationship between mobility and family/life course, suggesting that, “There is … a work–life balance that matches the acquisition of mobility capital against familial priorities” (2006, p 1113).

Specific attention to the influence of children on migration processes has emerged more slowly. Where this is recognised, children tend to be viewed as the passive appendages or, indeed, intractable obstacles to their parents’ migration.

Introduction

Since the early part of the 20th century there has been a continuing debate in the UK about the nature of a national health service. The establishment of the NHS in 1948 did little to end this debate that has continued over the past 60 years. The NHS was itself a compromise of interests – both political and medical – and discussion has repeatedly returned to whether the NHS should be a local or centralised service, what relationship it should have with local government, whether doctors, managers or politicians should run the service, whether it is affordable as a tax-funded service and so on. These debates remain as potent today as they were in 1948 and while it is unlikely that such debates will go away in the future it is perhaps a good time to examine the nature of the NHS 10 years after the election of the Labour government that has introduced political devolution, and towards the end of a three-year period when there has been substantial investment in NHS resources.

In 2006 the Welsh Assembly received devolved authority, providing the potential for wresting policy control of the Welsh NHS from Westminster and highlighting the increasing importance of political devolution in the UK. In addition, 2006 saw calls from the Conservative Party for an ‘independent NHS’ and from within the Labour Party for an independent NHS board and constitution. Health policy in England emphasised developing the role of the private and not-for-profit sectors in healthcare and further embedding a healthcare market, and so highlighted continuing debates about autonomy for, and within, the NHS. Yet, at the same time, in Northern Ireland, Scotland and Wales the emphasis has been on partnerships, professional engagement and central planning – often to overcome fragmentation and improve integration. Contributions to Social Policy Review over the past two years by Rudolf Klein (2005) and Ruth McDonald (2006) highlighted the development of patient choice and marketisation of healthcare. Developments through 2006 suggest that these are continuing themes, certainly within the English healthcare system. Recently there has also been an increasing concern with the relationship between the NHS and patients, service users and carers with an emphasis on self care and the role of health systems and the professionals who work within them in supporting self care (Kerr, 2005; DH, 2006a).

Introduction

The current trend in many European countries is shifting caring responsibilities towards the individual and promoting independence among older people. In this chapter it is argued that older people who need long-term care are most likely to be physically/mentally frail and they are more likely to be involved with multiple care actors. It for this reason that the power and autonomy of dependent older people is essential to ensure their quality of care is maintained. However, it also means that securing the autonomy of dependent older people within the complexities of the long-term care system remains a challenge. This chapter seeks to explore some solutions. It focuses on the entire long-term care framework and uses international comparisons to understand the range of policy options in order to learn from the successes (or failures) of foreign care systems. The countries selected – England, the Netherlands and Taiwan – were chosen because each represents a different welfare arrangement. In addition, many eastern countries such as Taiwan share with the West a similar trend of an ageing society (UN, 2001).

The chapter first covers theoretical views on power and autonomy as well as the care systems of older people in the three countries. It is concerned with issues of autonomy, globalisation, welfare typologies, needs, social inclusion and empowerment; the outcomes of autonomy are not purely ethical issues but consist of characteristics among the welfare systems, such as cultural beliefs and practical issues. The chapter then focuses on empirical research to offer an in-depth exploration of the conception of autonomy among the three care systems. It highlights older people's experiences of social and personal barriers that are inhibiting them from becoming more active socially and politically while in care. It also seeks to understand how their experiences of autonomy have affected their care and well-being. The concluding section draws together practical issues and offers signposts for cross-national learning.

Background perspective

Theories and policies in promoting autonomy in the long-term care of older people

In the context of long-term care, autonomy is crucial in determining quality of life and ensuring that older people are to be in control of their care (Österle, 2001; Boyle, 2003). The conventional view of autonomy comes from liberal bioethical thought associated with prioritising self-capability of independence, non-interference, self-determination, self-reliance and choice.

This chapter focuses on the challenges that older migrants present to established principles and systems of social welfare. It features the elaboration of policies for the welfare of foreign migrants since the mid-20th century in Europe, and more specifically the UK. The particular focus is on the circumstances of older people. Migration policy (or more precisely immigration policy) is very often seen as separate from social policy, while several important welfare measures, particularly those founded on social insurance and ‘intergenerational solidarity’ principles, implicitly presume a ‘closed’ or isolated national population and are confused by arrivals and departures. The disjunction creates a systemic tension between migration and social policies, which for half a century has been tackled by intricate special arrangements, as it were, to bridge the gaps: this chapter discusses whether this piecemeal, reactive approach is sustainable or needs to be replaced with more fundamental reform.

The chapter has five sections. It begins with further discussion of the challenges that large numbers of immigrants and emigrants raise for the established systems of state-supported and managed welfare in Western European countries. The second section describes the major types of ‘older foreign migrants’, showing that they are more diverse than is popularly understood, and specifies the kinds of challenges that they raise for established social policy. The third section is a selective guide to recent research about older migrants, and summarises the latest evidence about the number of UK state pensioners who are resident in foreign countries. The fourth section turns to the processes by which healthcare and welfare policies are ‘harmonised’ among the member nations of the European Union (EU), and evaluates the potential of current policies for achieving the required radical reform. The final section argues that the pressures for reform in certain underlying principles of ‘social insurance’ and the bases of entitlement will continue to grow, and require new kinds of ‘welfare contract’ for migrants of different ages.

Social welfare policies for migrants: the special influences

In states with popularly-elected democratic governments, social welfare policies in their broadest guise are generally a compromise between materialist and humanitarian ambitions. The parallel influences have been most evident in the elaboration of state educational policies since the last quarter of the 19th century.

Introduction

This chapter aims to enhance the understanding of social policy academics and practitioners with regard to the homosexuality of older men, with whom they may interact on a professional basis or write about through their research, without actively and consciously considering how sexuality can substantially influence aspects of daily living. In order to fulfil this aim, I first outline research to date on the size of the older gay male population in order to argue that this is significant enough to warrant more wholehearted interest from policy makers and service providers. Then, the discourse of sexual citizenship is discussed as this also contextualises my work. Finally, the substantive sections of the chapter introduce the research and the participants, before exploring decision making regarding coming out in a healthcare setting and the implications of different scenarios for the well-being of older gay men. It is argued that healthcare professionals require greater information in order to recognise the wider relevance of knowing a person's sexual orientation and to gain a better understanding of how best to discuss such subjects with patients who might be reluctant to access care and discuss their sexuality and relationships.

A number of professional responses are subsequently discussed that have implications for macro-level policy making and local service provision within healthcare institutions. This is also relevant research in light of the active ageing agenda and the government's aim to ensure later life is lived through activity, good health, secure income and independence. The cross-departmental Opportunity Age initiative launched in 2005 (DWP, 2005) reflects this and lays out the responsibilities of central and local government and governmental agencies, as well as older people and communities themselves. Arguably the efforts under the National Service Framework for older people (DH, 2001) concerning the NHS, and Opportunity Age (DWP, 2005), can only succeed if all aspects of older people's social worlds are recognised and accounted for.

The population

Older men form a relatively small proportion of the UK population, with the number aged 65 and over standing at 4,143,300, and with 1,754,200 men aged over 75 (ONS, 2006). A limited body of gerontological work focuses specifically on older men, with contributions made by Thompson (1994), Neugebauer-Visano (1995) and Schiavi (1999), who offer substantial, albeit quite heterosexist, contributions about older men and their sexuality.

Introduction

As Cantillon et al (2004) argue, what happens within households is often neglected. The family is a key site of distribution – of money, time and labour (see, for example, Lister, 2005), as well as other resources – but is often a ‘black box’, which is not investigated and in which equality is assumed. The qualitative study drawn on in this chapter is one element of a research project funded by the Economic and Social Research Council (ESRC) as part of the Gender Equality Network that tries to help open up this ‘black box’. The research aims to find out more about what goes on within heterosexual couples in relation to financial resources, and to use this to analyse the effects of changes in social security, tax credits and associated labour market policies. The project is timely given current policy changes in this area in the UK, which are affecting the resources available to men and women and the conditions under which these are given – and hence also gender relationships.

This chapter is based on some findings from semi-structured interviews with a sample made up of 30 low- to moderate-income heterosexual couples living in different areas of Britain, who had had children at some point, and where one or (mostly) both partners were of working age. Most were on means-tested benefits or tax credits at the time of the interview and/or had been in the past. The sample was drawn from a ‘booster’ group of low- to moderate-income households added to the British Household Panel Survey (BHPS) in the late 1990s for the European Community Household Panel (ECHP). (They had last been interviewed for this purpose in 2001.) Interviews were carried out individually rather than jointly, in order to explore the different perceptions of men and women about factual information as well as views and feelings. This decision could be criticised as resulting in unnecessary duplication. But we found that in a number of cases, the man and woman had different degrees of knowledge about the facts of their household finances, as well as different views.

Introduction

Government support for housing expenditure has a long tradition in Sweden. In 1936 a means-tested housing expenditure support was introduced for families with at least three children. The support was combined with an investment support to the housing where these families lived. Originally, only rented housing was eligible. Housing expenditure support to pensioners was introduced later. In 1946 the government decided to introduce a special means-tested local government housing expenditure supplement, in addition to the existing general housing expenditure supplement, which was an addition to the general pension. The local government housing expenditure supplement was not compulsory for the local governments, but an option. Today there are three housing allowance systems in Sweden: one for households with children, one for young households and one for pensioners.

The importance of housing allowances in Sweden is shown in Table 10.1. As is clear from the table, there was a dramatic decrease in the total expenditure on housing allowances as a percentage of GDP between 1995 and 2004. The number of housing allowance recipients also decreased, from 991,000 to 632,000 during the period from 1995 to 2003, the reasons for which are discussed later in the chapter. Due to changes in other housing subsidy systems, however, expenditure on housing allowances calculated as a percentage of all housing subsidies (excluding subsidies through the tax system) increased over this period, rising from 29% in 1995 to 88% in 2004. The main explanation for the latter is the phasing-out of the guaranteed interest subsidies for investment in and renovation of housing that took place between 1992 and 2000. The guarantee system was expensive for the state, partly due to the design of the system where the government took the whole interest risk and partly because the system applied to almost all housing production. From 2002, only a tax-compensating interest subsidy is paid to rented and cooperative housing that matches owner-occupiers’ tax relief for interest payments.

Table 10.2 shows the percentage of different types of households that received housing allowances in 2002. Lone parents and pensioners are the largest group of recipients with 82% and 23% respectively of the total population getting a housing allowance.

Introduction

Housing allowances have become increasingly important in Australia since the early 1980s, both in terms of the number of households assisted and government expenditure. Increasing reliance by governments on housing allowances has not been the result of an explicit process of policy development. Instead, two different types of housing allowances developed gradually and incrementally within the housing assistance and income support systems. Housing allowances are specific to either the public or private rental sectors and are the product of considerable dualism in rental market structuring (Kemeny, 1995).

This chapter traces the development of both types of housing allowances and examines their role, design and impacts. It raises a number of current policy debates, including prospects for integration of the two housing allowance schemes, the implications of ‘welfare-to-work’ policies, the role of housing allowances in developing the not-for-profit housing sector, and issues associated with designing housing allowances for a large country with significant differences in housing sub-markets.

The context for government housing assistance in Australia

Housing in Australia is a market commodity, almost entirely in private ownership and in which access is determined primarily by ability to pay market prices. In 2001, almost seven in ten Australian households were homeowners. This high rate has changed little for 40 years but is now bolstered by the more than four in ten households who own their housing outright with no mortgage, as shown in Table 2.1. Almost three in ten Australian households rent their housing, predominantly from private landlords and real estate agents. There is also a small social housing sector comprising 5.4% of occupied private dwellings.

Australian governments use a range of policy instruments to achieve housing outcomes, including tax expenditures, supply subsidies to social housing providers and personal subsidies to households. The most significant of these in terms of dollar value are tax expenditures for homeowners, in particular, exemption of owner-occupied housing from capital gains tax. The most recent estimate for 2001 suggests that the dollar value of tax expenditures for homeowners (A$21 billion) is about five times greater than direct government outlays on housing programmes (A$4.2 billion), although the different nature of assistance and data problems make such a direct comparison difficult (Wang et al, 2004, p 2).

Introduction

The aim of this chapter is to describe the development and functioning of housing allowances in the Czech Republic. After a short introductory description of the Czech housing system and policy, an evaluation of the allowance model is provided in two steps: first, by measuring the effectiveness of the allowance; and, second, by comparing the Czech model with the approaches applied in other transitional countries.

Under the communist regime, housing in the Czech Republic was subject to tight state control. With the exception of family houses, the entire privately owned housing stock was nationalised; subsequently, the creation of new housing cooperatives was allowed. Housing cooperatives were subjected to state administration and all rents were controlled by the state. Housing production was mostly shaped by the state, and as a result of the extensive housing construction programme financed from the state budget, the share of state rental flats in the total housing stock grew rapidly. The physical and aesthetic quality of these new flats, however, was very poor, with large concrete housing estates creating a new urban landscape. State housing policy in this period was based on the principle that a flat is such an important good in the life of a person, that the increase in construction, maintenance and management costs should not be reflected in household expenditures or rent increases. In the case of state dwellings, the rent was fixed at the level of 1964 prices through legal regulation. This necessarily resulted in the continually growing volumes of state subsidies for housing construction as well as for the operation, management and maintenance of the existing housing stock. The extensive, state-funded construction, management and maintenance costs of state rental flats were increasingly confronted with limited public resources and, consequently, other tenures (mainly cooperative housing and homeownership) gained in importance.

The ‘stabilisation of cooperative housing construction’ initiative was organised by housing cooperatives. The construction costs were covered using cooperative membership fees (on average approximately 18% of the total construction costs), state subsidies (on average approximately 56% of the total construction costs) and low-interest state bank credits with a 3% interest rate and 30-year maturity (on average approximately 26% of the total construction costs).

Introduction

Understanding the development of housing allowances within a particular nation state requires a historical perspective and a consideration of the way in which allowances are linked to state policy and practice. Further, current policy instruments arise out of both past decisions made and contemporary debates and understandings (Lowe, 2005). The history of New Zealand housing policy since the 1950s shows it has gone through a number of stages. This chapter tracks these changes to illustrate the changing position of housing allowances and their place within the overall housing policies of successive governments.

Housing allowances in context

In the 1950s and 1960s, the dominant thrust of public policy was to extend homeownership. The belief that underlay this policy was that a home-owning society was a more stable and prosperous one. Also, as this was a time of strong population growth and inward migration, there was a need to encourage the growth of the housing stock. Thus, much of the emphasis in housing policy was around increasing the housing supply. In the 1950s and 1960s, governments were active in both land development and providing a range of supports for first-time buyers to acquire housing, with this being targeted to the purchase of new housing. This policy mix provided a range of assistance that included the capitalisation of family benefit, a weekly cash allowance for each child, which could be used as a deposit and the provision of low-interest loans to modest- and low-income earners from the State Advances Corporation. In 1974, these loans were transferred to the Housing Corporation of New Zealand. The corporation was a multifunctional entity created to manage state stock, assist in the purchase of housing through the operation of lower-interest rate mortgages, to provide policy advice, and to undertake research with respect to housing affairs. The policies at this time with respect to homeownership were complemented by the provision of state social rented housing. However, the amount of such housing has always been relatively small and only briefly did this sector achieve 9% of the total tenure.

The welfare regime in place in New Zealand, from the 1930s to the 1980s, has been characterised as a wage earners welfare state (Castles, 1985).

Introduction

Great Britain has provided income-related assistance with housing costs since the 1930s, but it is only since the 1970s that it has assumed central importance within housing policy. It has also become a major component of social security expenditure in recent decades. At present, housing allowances in Britain take two major forms. The first is a scheme called Housing Benefit, which provides help for low-income tenants. The second is known as Income Support for Mortgage Interest and is available to home buyers who are in receipt of social assistance. Housing Benefit is by far the most important of these two schemes in terms of expenditure and the number of recipients.

During the last two decades, Housing Benefit has become the central component of government support in housing. It has also been instrumental in facilitating a major transformation in rented housing provision (Stephens, 2005). Yet it has also had a highly troubled history over the same period, with numerous problems, including both structural deficiencies and administrative difficulties. There have been several major reforms of Housing Benefit since the early 1980s and another reform is currently being piloted prior to being rolled out nationally. Tensions between housing and social security objectives have contributed to these problems (Kemp, 1994).

This chapter examines income-related housing allowances in Great Britain and focuses largely, but not exclusively, on the largest of these, Housing Benefit. The next section briefly outlines the housing market and social security policy context. Subsequent sections discuss the origins and development of Housing Benefit, the design of the current scheme, and its role and impact. The chapter then looks at Income Support for Mortgage Interest. This is followed by a discussion of the reform of Housing Benefit, the problems that reform was or is intended to address and the difficulties involved in attempting to resolve them. The chapter then discusses the impact of the new Local Housing Allowance, which is the most significant element of the reform. The final section sets out some conclusions.

Context

Although Esping-Andersen (1990) has described Britain as a ‘liberal welfare regime’, that characterisation is not strictly accurate. It is true that, in some respects, the British welfare state bears the hallmarks of a liberal welfare regime.