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
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Copyright, Designs and Patents Act 1988.
First edition published 1977 by Heinemann Educational Books
Second edition published 2001 by
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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
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Printed and bound in Great Britain by
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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
6
Part Two: Evaluations and Extensions
98
PART THREE: Universalism
7
Universalism I: Social Costs and Social Benefits
113
8
Universalism II: Integration and Involvement
123
9
Universalism III: Planned Redistribution
137
10
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
vi
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.
vii
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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
2
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
4
Richard Titmuss
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
6
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
8
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.
10
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
12
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
14
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
18
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
26
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
30
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,
The Definition of Social Policy
31
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.
32
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
The Definition of Social Policy
33
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.
34
The Status of Social Policy
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
The Definition of Social Policy
35
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
36
The Status of Social Policy
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
The Definition of Social Policy
37
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.
38
The Status of Social Policy
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
The Definition of Social Policy
39
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
40
The Status of Social Policy
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
The Definition of Social Policy
41
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
42
The Status of Social Policy
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
44
The Status of Social Policy
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
Some Methodological Considerations
45
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.
46
The Status of Social Policy
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
Some Methodological Considerations
47
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
48
The Status of Social Policy
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
Some Methodological Considerations
49
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
50
The Status of Social Policy
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
Some Methodological Considerations
51
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
52
The Status of Social Policy
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
Evaluations and Extensions
53
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
54
The Status of Social Policy
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
Evaluations and Extensions
55
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
56
The Status of Social Policy
– ‘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
Evaluations and Extensions
57
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
58
The Status of Social Policy
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
Evaluations and Extensions
59
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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The Status of Social Policy
‘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
Evaluations and Extensions
61
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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The Status of Social Policy
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
Evaluations and Extensions
63
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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The Status of Social Policy
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
Evaluations and Extensions
65
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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The Status of Social Policy
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
Evaluations and Extensions
67
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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The Status of Social Policy
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
Evaluations and Extensions
69
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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The Status of Social Policy
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,
Evaluations and Extensions
71
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
Evaluations and Extensions
73
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
Evaluations and Extensions
75
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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77
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
Evaluations and Extensions
79
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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81
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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83
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.
Evaluations and Extensions
85
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
86
The Status of Social Policy
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
Evaluations and Extensions
87
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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Selectivity
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.
Stigma
93
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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Selectivity
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
Stigma
95
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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Selectivity
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
Stigma
97
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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Selectivity
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
Evaluations and Extensions
99
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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Selectivity
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
Evaluations and Extensions
101
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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Selectivity
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,
Evaluations and Extensions
103
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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Selectivity
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
Evaluations and Extensions
105
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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Selectivity
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-
Evaluations and Extensions
107
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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Selectivity
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
Evaluations and Extensions
109
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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Social Costs and Social Benefits
Part Three:
Universalism
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Social Costs and Social Benefits
113
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
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Universalism
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-
Social Costs and Social Benefits
115
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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Universalism
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
Social Costs and Social Benefits
117
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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Universalism
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
Social Costs and Social Benefits
119
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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Universalism
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
Social Costs and Social Benefits
121
(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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Universalism
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.
Integration and Involvement
123
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
123
124
Universalism
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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125
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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Universalism
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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127
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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Universalism
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
Integration and Involvement
129
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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Universalism
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
Integration and Involvement
131
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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Universalism
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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133
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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Universalism
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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135
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
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Universalism
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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139
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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141
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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143
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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Universalism
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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145
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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Universalism
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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147
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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Universalism
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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149
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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Universalism
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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155
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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157
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,
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159
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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161
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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163
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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165
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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167
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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169
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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171
‘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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173
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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175
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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177
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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179
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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Universalism
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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181
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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Universalism
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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183
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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Universalism
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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185
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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Universalism
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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187
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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Universalism
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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189
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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191
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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193
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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Universalism
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
Evaluations and Extensions
195
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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Universalism
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
Evaluations and Extensions
197
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
Evaluations and Extensions
199
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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Universalism
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.
Quality
Part Four:
The Failure of the Market
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Quality
203
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
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The Failure of the Market
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.
Quality
205
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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The Failure of the Market
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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207
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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The Failure of the Market
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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209
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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The Failure of the Market
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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211
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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The Failure of the Market
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
Quality
213
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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The Failure of the Market
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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215
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 Failure of the Market
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
217
218
The Failure of the Market
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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219
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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The Failure of the Market
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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221
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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The Failure of the Market
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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223
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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The Failure of the Market
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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225
(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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The Failure of the Market
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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227
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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The Failure of the Market
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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229
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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The Failure of the Market
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
Quantity
231
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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The Failure of the Market
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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233
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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The Failure of the Market
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
Quantity
235
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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The Failure of the Market
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
238
The Failure of the Market
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
Price
239
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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The Failure of the Market
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
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The Failure of the Market
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
Evaluations and Extensions
243
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.
Evaluations and Extensions
245
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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The Failure of the Market
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
Evaluations and Extensions
247
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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The Failure of the Market
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
Evaluations and Extensions
249
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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The Failure of the Market
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
Evaluations and Extensions
251
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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The Failure of the Market
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
Evaluations and Extensions
253
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
Evaluations and Extensions
255
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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The Failure of the Market
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
Evaluations and Extensions
257
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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The Failure of the Market
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
Evaluations and Extensions
259
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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The Failure of the Market
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
Evaluations and Extensions
261
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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The Failure of the Market
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,
Evaluations and Extensions
263
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 Failure of the Market
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.
Evaluations and Extensions
265
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 Failure of the Market
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
Evaluations and Extensions
267
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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Conclusions
269
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
270
Richard Titmuss
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
Conclusions
271
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
272
Richard Titmuss
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
Conclusions
273
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
274
Richard Titmuss
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
Conclusions
275
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
276
Richard Titmuss
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
278
Richard Titmuss
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