Conditionality would have appealed to Rousseau. But its tying of benefits to some action by the individual in receipt has proved a dilemma from some liberal consciences. Benefits should be benefits. The poor cannot help it. It is illiberal to force people to register for work, attend an interview, train, and actively seek a job or whatever.
Despite this, governments of various politics have made welfare conditionality the norm in many countries. A central feature of British politics over the last decade, in December last year, John Hutton called for a “new contract of rights and responsibilities for the next decade” in order to address what he sees as a “can work – won’t work culture” amongst some claimants. Hutton termed it a “something for something approach: offering increased support in return for an increased obligation for people to do what they can to engage in [appropriate support programmes]”j
An established principle in the field of international development where debt relief is often dependent upon a recipient country implementing anti-corruption safeguards, the use of conditions to determine entitlement is increasingly visible in the domestic provision of public services. Jobseeker’s Allowance, the New Deal and Working Tax Credits all rest upon the premise that one must demonstrate that they are deserving of help in order for assistance to be provided.
The Welfare Reform Bill, of July 2006, requires applicants to attend Work Focused Interviews, agree an action plan and (where possible) engage in work related activity in order to receive the new Employment and Support Allowance. This year’s Budget introduced Activity Agreements and Allowances for disadvantaged 16-17 year olds setting out the expectation that young people progress into learning in exchange for financial support.
Welfare reform has taken much of the limelight in terms of conditionality in public service provision and much has been written about it elsewhere. But conditionality is used in many more situations to produce beneficial change.
Government is a tricky business, none more so than in seeking to change individual behaviour. Zero impact is the usual outcome for the average policy, if not the odd unintended negative consequence. In an age where Government struggles to be useful and where old New Labour is drawing to a close, much new policy may need conditionality within it to work.
“The problem is to find a form of association which will defend and protect with the whole common force the person and goods of each associate, and in which each, while uniting himself with all, may still obey himself alone, and remain as free as before.” This, said Rousseau, is the fundamental problem of which the Social Contract provides the solution.” Let us draw up the whole account in terms easily commensurable. What man loses by the social contract is his natural liberty and an unlimited right to everything he tries to get and succeeds in getting; what he gains is civil liberty and the proprietorship of all he possesses. If we are to avoid mistake in weighing one against the other, we must clearly distinguish natural liberty, which is bounded only by the strength of the individual, from civil liberty, which is limited by the general will; and possession, which is merely the effect of force or the right of the first occupier, from property, which can be founded only on a positive title.”
Is conditionality ok?
Each of us spends much of her/his life negotiating the conditions attached to our existence. Work abounds with them: the formal conditions are contracts of employment, appraisal, promotion, pay, professional qualification and practice, and diversity. The informal cultural conditions are sometimes more constraining on behaviour at work. Insurance premiums are conditional on health, lifestyle and claims history. Entrance to and practice of a religion carries many conditions contained in the small print of its bible. A legal marriage is conditional, and these conditions are reversed for co-habitees. The continuing adult relationship is a series of developing deals between the couple. Without the conditions the relationship will fade. Do conditions sustain love? Parents impose many conditions on their children (usually far too many).
Non-conditionality is the exception. Indeed, unconditional love for infants may be the only life engagement free of formal or informal conditions.
There is nothing new about conditionality in the relationship between the citizen and the government. If ………..then………….. Usually it is about boundaries of behaviour and sanctions for control: if you go over 70 mph then you will be fined and docked three points. Sometimes it is about criteria for acceptance: immigration, university entrance, building regulations.
Indeed, government goes further in its requirements of the citizen. Attendance at school for eleven years of a child’s life for c.40 weeks a year, for 5 days a week for 6 hours a day is mandatory. So far as I am aware, every liberal-minded person supports this mass detention and denial of freedom for educative purposes in the name of the public and individual good.
So why all the fuss about welfare conditionality?
The obvious answer goes back to its introduction when welfare was deliberately and explicitly universal and free at the point of delivery: the health service, unemployment benefits and pensions. The needs of individuals were clear and overwhelming. The issue was provision, not judging neediness nor the continuing motivation of the recipients. This was an age when the majority were disadvantaged. Means tests were opposed.
But times move on. The history of welfare benefits has been a diversification of role: benefits to the needy; benefits as a right; and now benefits as a lifestyle choice. Where benefits alleviate hardship, few would argue with this role and with its value. But alleviation should be an intermediary objective. A lifetime of hardship (and its alleviation) is in neither the individual’s nor society’s interest. A complete solution incorporates elimination of the hardship (and of the benefit). Too often, welfare objectives focus on the immediate need to the exclusion of the longer-term cure, prevention or solution. Immigration and asylum policy suffers in this way too, in neglecting to consider its impact on the development of the country of origin and thus on the elimination of the drivers of immigration, and in neglecting its impact of the motivation to develop the employability of the socially excluded”.
Unconditional benefits have produced poor results: in the life and work motivation of the individual; in the resentment of those footing the bill; and in legitimising and enabling social exclusion: providing those in the “sinks” are not starving they can be left with no obligation on the rest of society to help them into the mainstream. Elsewhere, the absence of conditional responses to drug, drink, physical and sexual abuse and the reliance on the punishment “solution” and on the criminal justice system for nearly all of the 20th century has maintained the cycles of abuse and condemned many to a lifetime of its consequences.
The issue then is not: conditionality, to be or not to be? Nor: can conditionality and a liberal conscience co-exist? They can and do, but not if the conscience has been sterilised with a wrapper of political correctness. The issue is making conditionality work.
Models for conditional approaches
A reasonable amount of application and experimentation in the UK and other countries in schooling, drug abuse, parenting and health care amongst others means we can start to see where and how to apply conditionality and to draw from the lessons learnt. As ever, the quality of implementation is key.
Broadly, conditionality has been applied in three ways:
The action/incentive model is the most straightforward. In 1993, the Bangladeshi government launched the Food for Education programme (FFE) – replaced by the Cash For Education (CFE) programme in 2002. Poor families rarely sent their children to school as they were needed to help the family earn a living by looking after other children or by working themselves. Under FFE, children receive monthly rations of rice or wheat if they attend school for a least 85% of their classes. The objectives to increase enrolment and attendance rates and to limit drop-outs have been met according to the evaluations by IFPRI.
The success of FFE may be no surprise. The action is very clear – attend school – and this has strong public good and individual goal outcomes. The incentive is very clear – free food – and it substitutes exactly for the motivation for staying out of school.
Since 1997 Mexico has run the PROGRESA (Programa de Educación, Salud y Alimentación) programme. This provides cash and other transfers to mothers in poor households, on condition that their children attend 85% of school days and their family visits public health clinics and participates in educational workshops on health and nutrition, as well as pre-natal care and immunization. The programme started off by targeting rural areas but has since expanded into poor urban districts as well.
The payments extend from grades 3 to 9 and increase as the student gets older, from about 10 to 35 dollars a month, with girls being paid higher than boys because girls have a higher dropout rate. The average monthly payment (received every two months) by a beneficiary family amounts to 20 percent of the value of monthly consumption expenditure prior to the initiation of the program. Families are also given grants to buy school supplies and monthly food subsidies if they get medical checkups, immunizations and attend health lectures.
In 2000, some 2.5 million rural families received the benefits valued at about $1 billion, or 0.3% of Mexico’s GDP. IFPRI analysis indicates that improved nutrition and preventive health care in PROGRESA areas have made younger children more robust against illness. Specifically, PROGRESA children aged one to five years of age have a 12 percent lower incidence of illness than non-PROGRESA children. Child growth has also increased, by 16% per year (about 1 cm) for children between 12 and 36 months of age.
PROGRESA has had a significant impact across the region with Argentina, Brazil, Colombia, Ecuador, Honduras, Jamaica and Nicaragua all starting similar Conditional Cash Transfer programmes.
Interestingly, both FFE and PROGRESA are promoting universal schooling in cultures where, historically, limited participation has been the norm. In the UK, the norm (culturally and in law) is universal schooling and the approach here to conditionality is “inaction/loss” rather than “action/incentive”.
Under the inaction/loss model, if the person fails to do something then the benefit is withdrawn. This model is widespread for the continuing receipt of unemployment benefit in, amongst other countries, the Netherlands, USA, Australia and the UK. The evaluations have been widely reported and discussed elsewhere and are not repeated here.
The behaviour/avoidance model requires some form of treatment or course to be followed intended to change behaviour in order to avoid, typically, imprisonment or a fine.
Parenting Orders have been available nationally since June 2000, following a pilot. These fit the “behaviour/avoidance” model in that parents and their children are ordered to attend courses to avoid a fine or imprisonment. The Policy Research Bureau evaluated the parenting programmes, a mandatory part of the Parenting Orders, from 1999 to 2001). The conviction rates fell from 89% in the year prior to the programme to 61.5% in the year after. The average offences per child fell from 4.4 to 2.1 (Policy Research Bureau).
These parenting programmes have been a stunning success, rare in any branch of public or private endeavor. On reflection, this may not be surprising since parenting is amongst the most complex of occupations for which, by and large, none of us receive training. Add to this the pressures of multiple deprivation, then a programme which shows people to an extent how to develop and control their children, albeit late in the day, must be a highly valued experience.
Conditions for Sustainable Changes
Drawing on this and other experiences, the tangible conditions for securing beneficial change in the intangible or unmeasurable world of social change start to take shape.
Conditionality is reciprocal
Conditionality is about setting boundaries and obligations. At the margin, some unfairness may occur, the net of which should be less than the unfairness arising from an unconditional regime.
At the same time, those developing the conditional framework should accept the obligation on them to ensure the circumstances exist where the conditions can be met. Without this, in the long run, the sense of hopelessness will resume.
The concept of “mutual obligation” has been taken on board by the Australian government which recognises their part of the bargain is to stimulate economic growth so that jobs are available for the unemployed to get.
By contrast, the socially excluded in Britain have little chance of sustainable employment in competition with managed migration. Selected immigrants fill skills gaps for employers easily, with their infrastructure, housing and congestion costs falling broadly on national taxes and on price increases. The long-term unemployed need much support and motivation to fill the same skills gap. New Deal has been successful for some but long-term unemployment has increased from __________ to _________ since 1997. Much of the support needed is long-term and requires big change, for example, to schooling.
Initiatives using conditionality to bring about behavioural change will work to the extent to which they are appropriately resourced.
Design the services around the individual
The best DTTO pilots had the highest number of reviews being carried out by the same judge who sentenced the participant. Evaluations found that the offender feels he is not anonymous in a large system but that the authorities get to know him as an individual and are interested in his personal progress. The Australian “intensive assistance” programme as part of their conditional package for job seekers is proving effective (getting 36% of jobseekers into employment compared with the flagship Work for the Dole programme’s 33% success rate) because it is individualised assistance with one to one interviews to determine an individual’s skills and weaknesses, and recommends jobs accordingly.
Take a systemic approach to problem solving
All sustainable organisational theory and practise now takes some form of holistic approach to change be it systems thinking (reference), organisational alignment, the Burke-Litwin model, or the 7S approach. Pressing one button alone very rarely has the right effect. Societal change is complex. Without a systemic view the law of unintended consequences will reign supreme.
Use an effective multi-agency approach
Conditional benefits and conditional sanctions require a number of actors to work together – the criminal justice system, health and social services, and education, for example. Coordinating housing authorities, courts, teachers, landlords, healthcare workers and a host of others can present a significant obstacle to the effectiveness of a conditionality based initiative. DTTO pilots had 56% of their offenders attending without health and social worker’s recommendations, meaning some of these offenders were not suited to the DTTO programme. Making courts aware of the parenting programmes so that there were more referrals and greater use of Parenting Orders by sentencing judges was seen as a major problem by youth offending teams and social services. Many parents who may have benefited from parenting classes were not given the opportunity. Youth offending teams found it hard to track breaches of Parenting Orders once they had been handed to police, and then found sanctions handed down by courts too lenient – undermining their role in enforcing Parenting Orders as a serious sanction. The DWP do not coordinate well enough with employers, so that the Adult Learning Inspectorate found that 60% of training providers used in the New Deal training option were inadequate and not suited to employer needs (and thus unable to get the New Dealer’s a job).
Use effective implementation organisations
Principle, policy or strategy developed in isolation from practicality and implementation is usually of little positive value and sometimes detrimental. Asylum is another one of those areas where the application of good liberal principles without reference to the reality of outcomes produces a mess.
DTTO is an effective condition-based solution but is flawed by the standard Whitehall delivery process (silo-budgeting, financial accountability paranoia, delivery becomes procurement, procurement as a public academic examination process tinged with power, low knowledge clients, no ownership).
Any conditional solution can only be as good as its implementation organisation.
The best is the enemy of the good
The least successful DTTO pilot area was Gloucestershire, which was found to have unrealistically high expectations of its addicts and did not give them credit for reduced drug use but rather insisted on completely negative drug tests. Liverpool was found to have a more positive approach, with staff who understood that addicts would take at least 3 months to respond to the programme.
The Family Law Act information meetings were starting to produce small benefits. Perseverance was needed, not abandonment.
People respond to, not resent obligations
Carol’s son had been in trouble with the police for years. She couldn’t think of a way to stop him, and his behaviour was beginning to affect her younger children. Then a court ordered her to attend a compulsory parenting course at Relate, Peterborough.
“It felt like a punishment to me. I was brought up in care and resented being told what to do. The first time I went was a bit nervy. But I tell you, I love these people – every one of them. Even the counsellor was fantastic. She was down to earth, not like “You’re a bad mother”. I learned how to speak to people, how to get people to listen to me. With children, you know how you say “You little…” Well, they’re not going to listen to that, they will just shut off, but if you start with “I”, they can’t help but listen.
The skills we learnt should be on the school curriculum. Then we’d know! Why should I be so desperate to learn this? My son (now 15) was doing car crime, driving whilst disqualified. I had the police at my door almost every night for four years. Now he hasn’t been in trouble for four months, touch wood.”
Individual behaviour is often as much the product of the local prevailing culture as it is of the individual’s emotions and circumstances. Thus, concentrating individual support in a coherent geographic area can multiply its impact by shifting the prevailing culture espoused over the garden fence. It is rare to find government targeting social programmes in this way with sufficient density to change the culture. How many parents in the Kings Norton estate in Birmingham have been on a parenting course?
An exception is the FFE programme where economically backward villages were selected and almost all schools in the village granted FFE, be they governmentally-run or not. Children were targeted by land ownership (landless or near landless households), by their parent’s occupation (day labourers and low pay artisans) and their family structure (female heads).
Properly thought through and applied, conditionality has a place in social change. Are there other areas where conditional approaches could produce benefits? Divorce is considered first below because of its recent chequered history in Britain compared with the successful experience internationally. Thereafter, the family, health services, energy use and prisons are considered.
This story has much relevance for the future application of conditionality. It is a case of apparent failure, and has applicability well beyond the fields of benefits, social exclusion and abuse: the introduction of conditionality to divorce proceedings in the Family Law Act, Part 2. The Conservative Lord Chancellor Lord McKay steered it through Parliament in the mid 90s.
Piloted from 1997 to 1999, Part 2 stipulated that people seeking a divorce must attend an information meeting to try and a) save saveable marriages by working out if a divorce was really necessary. When that was not possible, they would b) help promote mediation services rather than litigation, and c) ensure children had good information and contact with both parents, using a parenting plan.
The interim results in 1999 from the pilot areas in the evaluation by Newcastle University were enough for the government to decide not to implement Part 2 of the Act, and it was repealed in January 2001. The final results of interviews of the couples who had attended the information meetings found:
- 70% said the information meeting had made no difference to their decision whether or not to use marriage support services and 73% said the meeting did not affect their decision on whether to divorce
- 7% said they went to mediation as a result of the information meeting
- 4% said they were less likely to go to mediation as a result of the meeting
- 12.2% attending the information meeting then went on to attend marriage counselling, 1 in 10 said the information had effected their decision a lot, a further third said the information meeting had affected their decision “a little”
- 20% said the meeting made divorce more likely
- 7% said divorce was less likely
- the information for children was unpopular – only 16% of parents passed on the child-specific leaflets to their children. The most common reasons were they felt their children would be upset by the information, the child was too young, or that it would be better coming from the parent rather than in a document.
- 10 out of the 123 interviewees said the information meeting helped facilitate a discussion with their children.
In general it was reported that the information meetings were too inflexible and came too late to help – the meetings were provided for those seeking divorce – thus the marriage had broken down and one or both had decided for definite to divorce. Information on alternatives was thus unheard. The information meeting was mandatory for the person requesting divorce, but optional for the partner. Only 6% of information meetings in the pilots were attended by both partners.
So the evaluation looks conclusive. Except that this use of conditions came at the start of a very long campaign intended to change divorce from an intensely adversarial to a non-adversarial process (albeit still painful). Such a major change of mindset throughout society takes a lot. Fortunately, governments of the day have not shown such lack of commitment in the face of objections to drink-driving laws and campaigns or the 70% reduction in deaths would not have been achieved. This took 30 years. The figures for the outcomes from the FLA Part 2 were, in fact, impressive for such an under-developed set of pilots running over such a short time. 12.2% went to marriage counselling and 7% said divorce was less likely. If this meant that only 1 in 20 of couples who file for divorce restore their relationship, the savings in legal aid, benefits and the costs associated with the actions of children with impaired parenting would pay for the FLA services.
A 5 % reduction in drink-drive deaths in the first three years would have been hailed as a victory, rightly. If the change in mindset stimulated by the FLA had reasonably followed the drink-drive trajectory we would now be some way towards a “good divorce” culture with all of its benefits. Good divorce means making really sure this is the best option and, if it is, placing the emotional development of the children at its centre. Ironically, much of this means getting the judicial and legal systems, and their costs, incapacity to deal with the complexities of family life, and their promotion of the adversarial, well out of the way. Thus a far-sighted Act using a novel approach to conditionality came to grief. (A lose minister, the Law Society and an unpopular lead civil servant appeared to be the causes of death.)
The FLA is a variant of the action/incentive model in the sense of: if the citizen gets educated (the action), then he/she can get divorced (the incentive). Philosophically, objections are raised on the grounds that divorce is a private matter and the state should not intrude in this way. The counter view says the public good is at stake in terms of the public cost and the impact of the children’s behaviour, and therefore the state role is legitimised. Further, who represents the children? In the evaluation above, it is unsurprising that information for children was unpopular with the parents as it brought their needs into the equation when, often, these are unknown or relegated by the couple. History says that major social change has often been legislation-led as a signal and a stimulus – drink-drive, race, equality are good examples – alongside long-term campaigning by public authorities and others. Further, in the long run, a good divorce process would mean less state involvement as families learn to handle this process well both for their own and the public good.
The conditionality message is making a comeback. Mrs Justice Bracewell, a judge from the Family Division, is pressing for a pilot study into a new scheme that expects couples to attend expert briefings on post-separation parenting before they can have a judicial hearing. Under this scheme, parents would be required to go to mediation – with the specific task of working out a long-term parenting plan and contact arrangements.
This scheme is modelled on successful schemes in the US and elsewhere, started as long ago as 1994. Couples are told clearly, before any hearing, that proper contact with both parents is in the interests of the child and that their rights to custody may be jeopardised if they do not honour this principle. Setting absolute boundaries like this lessens the use of the children as transmitters of couple conflict and may, curiously, enable the couple to abandon the conflict as parents. They no longer feel wedded to the conflict (presumably, in part, as a self-justification to pursue a destructive and selfish course) and are “given permission” to cooperate.
There is money to be saved. About 80,000 parents a year issue contact proceedings in the UK. Contested hearings could be avoided in 75% of cases, one district judge estimates. Further, CSA payments are estimated to be £3.4bn in arrears. One response may be to use the “inaction/loss” model via docking benefits and wages or confiscating driving licences. A more holistic look at the problem finds as many as 80% of the non-paying fathers doing so because of inadequate or no access to their children. Non-payment of CSA money is an understandable reaction – “if I can’t see my children I am not paying for their upkeep”. The “action/incentive” model applied up front, ie divorce education plus an agreed parenting plan, would prevent most of the contested access and lead to CSA arrears dropping very substantially.
Is there a case for a pre-nuptial agreement on the children – a rather more important “output” or “asset” of the relationship than the finances? This would set out the rights and responsibilities of the couple and of the children in the event of a divorce.
In her report Government and Parenting: Is there a case for a policy review and a parents’ code? (JRF), Clem Henricson sets out the case for the latter against which policies could be assessed and inconsistencies and contradictions identified. It would send out a clear message about parents’ responsibilities and rights.
On the responsibilities side, for example, it might require parents to “foster a child’s development and happiness” in a number of areas (education, physical safety, and physical and emotional nurture). Parents might also be expected to foster the child’s pro-social behaviour. In return, they could expect a right to financial support, free pre-school, primary and secondary education, access to information and advice about child-rearing.
Equally important, a parents’ code might also influence public attitudes to parenting, giving parents – at last – a more fully recognisable public role. Thus conditionality would be approached in the round in setting the parameters for the relationship between the parents and the state.
Conditional Health Services
The National Health Service may have more opportunity for conditionality than many services. Some are obvious. IVF is very expensive. By comparison, Foresight is very cheap and has none of the birth defect side effects, indeed it comes with benefits. Foresight is based on eliminating toxins in both conceivers, and on balancing vitamins and minerals. It is effective in reducing infertility and eliminating defects. The action/incentive model would be if you follow Foresight and still nothing happens then you can go on to IVF. I wonder what the financial and non-financial benefits would be? As with parenting orders and post-divorce parenting plans, the obligation produces benefit by removing the notion of being a captive of circumstance.
A free at point of provision health service is unsustainable without conditionality. The tax burden would be unacceptable. The alternative is a French or Dutch system with payment as the means to control demand and heavy subsidy to guarantee access. Conditionality is a partial means to control demand and promotes people taking greater responsibility for their health.
Perhaps the biggest challenge to behaviour this century will be in energy use. The risk of cataclysmic climate change is sufficient to take major precautionary action on carbon output and therefore to reduce non-renewable energy use. At this point, established patterns of work-life, home-life and holiday-life are challenged, we tend to bury our heads in the sand and governments back off.
I have not got much further than to wonder whether conditionality could help. Here are some ideas.
One obstacle to greater holiday travel by train in Europe is the time penalty. Could government agree with employers to allow an extra day away from work for employees taking the train?
The major obstacle in reducing energy consumption in the home is the motivation and the skills to do so. Is education one answer, using the parenting programmes as an exemplar? The action/incentive model could see a VAT reduction on gas and electricity for a year in return for attendance at a well-run sustainability course designed to motivate people to reduce consumption and giving them the skills to do so.
Believe it or not, the criminal justice system has long had forms of conditionality: conditional discharge, probation and parole. These have all been behaviour/avoidance models: if you do not break the law and do adhere to supervision then you will avoid punishment in the form of prison. Classically, imprisonment itself fails to use action/incentive models and fails to apply the lesson of “conditionality is reciprocal”. Thus the period inside could be used to acquire and demonstrate the work skills needed for a permanent job (for which demand exists: plumbing springs quickly to mind) and, preferably, to go further and acquire the emotional awareness and relationship skills to provide, at least, some family and community stability. Prisoners would be released on condition and whenever a reasonable (and not overly onerous) set of skills had been acquired. Continuing support and education would be needed thereafter to find housing and a job on release. Of note, is that the problem of rehabilitation in Britain has not been of the prisoners but of the prisons. Long before over-crowding dominated, our inert prisons have failed, failed and failed again to rehabilitate on any scale and with any consistency.
Where to Find Conditional Opportunities: Free Money & Offences
The opportunities cited above for extending conditional approaches need proper planning and implementing. The exception is good divorce – a travesty and a tragedy for many parents and children – which just needs to be got on with.
The places to look where conditionality could have benefit are where “free” money or service is provided – benefits and health for example – or anywhere offences occur and the justice system lumbers into action.
Conditionality is not a panacea for all social ills, but it does have its place and, at times, an important place.
I see it as part of the wider movement to re-empower citizens and communities to take more control of and responsibility for their lives and the things they need for their welfare and development. The old way of government taking unto itself service provision, resource allocation and controls, with citizens as passive and separate consumers, users or recipients with the only institutional connection between the two being occasional elections, is evidently on its last legs. The average citizen has more influence over Big Brother than over the NHS. Conditionality, rights and responsibilities, public engagement and deliberative democracy are all part of the same thrust to re-motivate and re-engage, and to redistribute power. But with power comes responsibility. Conditionality is also about putting the responsibility alongside the power.
Finally, conditionality is about reconnecting money, output and accountability for individuals and for organisations too. Life used to be relatively simple: roughly, something beneficial was done for which payment was received and for which the individual/organisation was effectively accountable. Now, top executives can increase their reward through failure, electricians increase their pay by neglecting the points, London cab drivers be paid for standing still, media companies be paid to advertise pseudofood which leads to obesity for which the NHS pick up the bill, local authorities be responsible for expenditure four times the sums raised in local taxes for which the local electorate holds them to account, and surgeons be incentivised to maintain waiting lists. Hardly surprising, with these examples, that benefit payments are missing their mark. A mass rewiring of the connections between money, output and accountability is needed. Who am I paying? What am I getting? Who is accountable and how? Conditionality is a part of this rewiring.