Development of Health Care Policy in Great Britain

The development of health care policy in the last one hundred years has been shaped by many factors. These factors are social, economic and political and include poverty, de-industrialisation and different political ideologies. Social attitudes changed over the nineteenth and twentieth centuries and were the main driving force for the development of health care policies.

In the early 1900s attitudes were changing and people were becoming more aware of social conditions within the country. The Boer War and the two World Wars had shown politicians that the country was poor, unfit and extremely unhealthy. Unemployment was rising and more and more people were becoming dependant on help from the state. At this time we had the political influence of a Liberal Government whos ideals described as social democratic, would give rise to the health service. Social democratic ideals concerning health care were that care should be available on a needs basis rather than for those who could afford it and should be provided by the state. They believed that all people should be free from poverty. The social democrats thought that its people were the governments responsibility to look after. This ideology led to Labour exchanges and National Insurance being set up in 1911 to help those who were sick and out of work. Women were given the vote and they helped to highlight social conditions of the nation. Poverty was rife and was a drain on the economy, and was one of the main reasons the population was so unfit and unhealthy as we will see later.

In 1942 Beveridge produced a report that was designed to counter the five social giants of idleness, ignorance, disease, squalor and want. The report was lengthy and considered the whole question of social insurance, arguing that want could be abolished by a system of social security organised for the individual by the state. Beveridge recommended the establishment of a national health service, national insurance, assistance and family allowances. He also stressed the importance of full employment. Although not entirely as Beveridge wished, a newly elected Labour government, adopted measures that formed the basis of the British Welfare State. These measures that were introduced included a comprehensive social insurance policy that covered unemployment, sickness, maternity, and widows benefits. Pensions, childrens and guardians allowances were also available. A free national health service, training and industrial injuries schemes were set up. Full employment became government policy. Together these developments created the welfare state, a system of social security guaranteeing a minimum level of health and social services. Ideally the welfare state aimed to relive poverty, reduce inequality and achieve greater social integration. In many respects this has had a great influence on peoples lives, people are living longer, are healthier and standards of living have improved. The welfare state has failed to give full employment or eradicate poverty.

Poverty is still in existence today in Britain and is a financial drain on the Welfare state. Poverty has changed over the years with a shift from mostly absolute poverty to relative poverty. The early 1900s saw many people living without proper shelter unable to feed or clothe themselves this is absolute poverty. The introduction of the welfare state has helped to reduce absolute poverty in so much as today it is limited to homeless people. Relative poverty is very high in todays society. Relative poverty is about social exclusion and not having the things that the nation as a whole deems necessary. An example would be not having a television or not being able to go out and socialise. The main reasons for poverty today are vast but include low paid jobs, high unemployment, poor benefits for disabled and sick and increasing numbers of one parent families. A survey in 1992/93 found that 25% of the population i.e. 14.1 million people were living in poverty of which most were of ethnic groups, women or lower class. Many of these people were unemployed, on a state pension or in low paid part time work. This led to the conclusion that poverty was mainly caused by three factors. The three factors are access to job market, cost of living (extras e.g. children) and poor policies to deal with them. Poverty has far reaching effects on the health of the nation as was shown during the wars. Poverty and health are definitely linked and not only are the poor more likely to suffer from ill health and premature death, but poor health and disability are themselves recognised as causes of poverty. Surveys have shown that the majority of people regard the poor as being responsible for their own poverty and are suspicious of those who live for free on government handouts. Many people believe that those on welfare could find work if they were determined to. Income is a key resource for families and the ones with low incomes are least able to afford or have access to good housing, generally live in poor areas with no play facilities for children and have poor access to health, education and leisure services. Poor incomes dont enable these families to buy the correct foods thought to be important to health (e.g. fresh fruit and vegetables) or to be able to keep their homes dry and warm. Poverty affects the health of people from birth to old age. At almost every age, people in the poorer social classes have higher rates of illness and death than people in the wealthier social classes. Studies of child mortality clearly show a difference in causes of death between the social classes. Low birth weight in babies is associated with social class and thought to be associated with parental poverty and poor maternal environment rather than the quality of medical care. Childhood death rates from accidents (the largest single cause of death in childhood) are a clear example of how living in a poor area, without safe play areas has a serious consequence on the health of children. The poorer social classes are ill more than their richer counterparts and use the health services more often. Almost all major killer diseases affect manual classes more than non-manual classes and in some instances are twice as high. There are two main explanations for this, which can be seen, as cultural and material. Cultural explanations look at how health inequalities are rooted in the behaviour and lifestyles of the individual and that those suffering poor health have different attitudes, values and lifestyles which mean they dont look after themselves. Inadequate diet, smoking, drinking and lack of exercise all have direct effects on the health of a person. Low income confines the type of food that poor people can buy and therefore the amount of nutrients an individual can eat. These adults in low-income families continue to smoke and drink excessively or take drugs. Even though these adults know the adverse affects it will have on their health, they continue with this lifestyle because to them it is a way of coping with the everyday stress that living in poverty has on them. III health caused by poverty is therefore a drain on the welfare state in costs to the NHS and benefits paid through sickness and disability.

Society has changed over the centaury and has impacted on health policy. Family structure has changed from the nuclear 2 parent and children to stepparent families (reconstituted) and lone parent families. Extended families are fewer as people move away to find work. Divorce rates have also climbed because women have become more independent and have more rights. More women are working and have higher expectations of marriage with less religious meaning behind them. The change in family structure has also had an effect on demographics. As more women choose careers less and less babies are being born and as a result the birth rate is decreasing. The welfare state has improved living conditions and as a result people are living longer. These two facts will result in an aging population that has far reaching implications. An aging population will result in a greater percentage of state dependant people with less young people to pay for the services. This is a problem, which the Conservative government started to address in the 1980s, and is continuing for the Labour government today.

Economic changes have also contributed to social policy. Since the setting up of the welfare state Britain has undergone major changes in the types of work available. Britain has lost its National industries e.g. shipbuilding, mining, manufacturing and almost our fishing industry. These industries have been replaced by service industries like care, retail, finance and leisure industries this is know as de-industrialisation. During the industrial era men brought home a fairly decent wage and had a secure job. Today working within the service industry people are working longer hours for less pay, which has helped to increase poverty. Many jobs are part-time and therefore no national insurance is paid to sustain the welfare state. The costs of the ever-growing health service are increasing all the time. As already mentioned poverty brings ill health with heart disease, cancers and recently diabetes which drains money from the NHS. The aging population also brings higher costs to the health service, as more elderly people will require care with less people to pay for it. Other costs to the health sector are the costs incurred with drugs in administering and research. As more people use the NHS the more drugs must be paid for. The cost of drugs can vary from a few pence per tablet to tens of thousands per tablet. As more complicated therapies and equipment, such as scanners, are used these drive up costs. Staff costs are the biggest drain on resources for the health sector and will increase, as more people need services. This problem of cost is compacted by the fact that there will not be enough younger people to pay for the ever-increasing costs of the NHS. This has lead to changes to the health service over the years with the most radical coming in the 1980s.

The 1980s saw Britains first women Prime Minister Margaret Thatcher, head of the Conservative government. The Conservatives were the first party to reform the welfare state since it was set up in the forties. The liberal government in the early 1900s had set up the pathway for the welfare state incorporating their ideologies of free care for all and their vision of a poverty free nation. The Conservatives ideologies were very different and were know as right wing. Conservatives believed in market forces and capitalism. They believed that the state should not intervene in business and that people were responsible for themselves. Privatisaton and de-industrialistion came about which resulted in high unemployment and increased poverty, which was a drain on resources. This led Thatchers government to consider privitasation of the NHS. This was considered too big a step so the free market was introduced. The Conservatives believed that only people whom really deserved help, disabled and long-term sick should get free care and everyone else should pay for care. This resulted in the setting up of hospital trusts and private medicine. This was an attempt at reducing the NHS costs paid for by taxation.

In 1989 a white paper Working for Patients was introduced and changed the funding structure of the NHS. It still upheld the Liberal ideal logy in providing mostly free services at point of delivery with universal care still funded through general taxation. It introduced competition and market forces. The market force includes having service providers and buyers. G.P.s, insurance companies and health boards were the buyers, i.e. they purchased services for their patients. Hospitals and clinics are the providers of services and compete against each other for custom. This was supposed to encourage hospitals to raise their standards of care in order to attract business. Contracts would be drawn up between the buyers and providers and the money (or bill) would follow the patient around from service to service. G.P.s were encouraged to become fundholding i.e. take control of their own budgets. This allowed G.P.s to say how their money was spent and gave freedom to upgrade and add services to their practices. Hospitals were allowed to become Trusts this meant it had opted out of the system and could now own its own assets and set its own pay and staff levels. In other words hospital trusts were a business just like any other. The idea was that this would improve care delivery tot the patients as hospitals that were poor would fall to the wayside and hospitals that delivered good care and services would flourish. The white paper also outlines specific measures to improve patient care. These were pleasant waiting areas, easier complaints system, individual appointments and clearer information for patients. The conservatives hoped that by introducing a health service that was patient controlled and had more control of its finances would improve efficiency, productivity and accountability as well as provide better services for the nation. These policies allowed people to choose their care and allowed a new industry to appear.

Private medical insurance popped up everywhere and grew from 4% to 25% of the population in the space of a year. There are three main providers Bupa, PPP and Norwich Union This system has been accused of bring a two-tier health system to this country in which the rich can then jump waiting lists. The idea is that a person insures himself or herself against accident, injury or illness. They pay monthly premiums and will in return receive prompt treatment and monetary payment for loss of work. This of course is only available to people with a substantial income and personal insurance is the smallest part of this business. Companies on the other hand are the biggest users of private medical insurance. It makes sense for companies as insurance can be offered as a perk of the job justifying a poorer wage. Also it pays to have your employees back to work as quickly as possible. The insurance companies will also help talk to the many different sectors that provide care freeing up more time. This is why companies have embraced private medical insurance.

Many different sectors are involved in the provision of care. The state sector i.e. hospitals, G.P.s, social workers and residential care provide care to all and are funded by the state. The private sector i.e. private hospitals/ residential and nursing homes provide care to those that can afford to pay for it or are insured. Voluntary agencies such as Age concern or W.R.V.S depend on charity to exist and provide access to transport, services and equipment to name a few. Family, friends and neighbors also provide care, this is known as the informal sector. This is dependant on the person being close to family who are in a position to help. The state sector carries the bulk of health care provision backed up with the voluntary agencies. The private sector handles a smaller proportion of the care provision and sometimes relies on the state to plug gaps in their services. This mish-mash of care providers is known as the mixed economy of care and has risen from the polices adopted by the conservatives and legislated with the working for patients paper in 1992. Today we have a Labour government who are looking to reform the health service again with polices that are still along the right wing ideologies of a free market and state funding through taxation. Only time will tell as to how this will affect the welfare state as it stands today.

The development of health care policy over the last 100 years has shaped the welfare state to what we have today. The social, economic and political influences came about from the country needs for a healthier more educated society for protection and advancement in a modern world. The advancement of womens rights and the vote was instrumental in social policy becoming a main concern of governments. The Beveridge report showed the state of the nation and gave its recommendations on how to eradicate poverty. The welfare state was set up to achieve this and was quite successful in helping living standards improve. The welfare state did not remove poverty as many people today still live impoverished lives. Poverty has changed in that there is less absolute poverty and more relative poverty than before. Social attitudes have changed with people having greater expectations in all aspects of life. This has lead to changes in family structure with more families being reconstituted than nuclear. Demographics of the country have also changed with fewer women having babies and those who do have fewer children. People are also living longer due to medical intervention and advances. This has far-reaching implication to the welfare state as more people becoming dependant on it with less people to pay for it. De-industrialsation has resulted in more people living in relative poverty as job security is gone and people are working longer hours for low pay. This causes more ill health in the poorer section of society who are dependant on the state for care. This costs the NHS more money in staff, drugs and equipment. The liberal and conservatives were the main political influences on the welfare state. The liberals believed in free care for all whereas the conservatives believed if you could pay you should pay but also gave free care to all if needed. The conservatives brought in market forces and gave birth to the mixed economy of care that exists today. All these policies have had their good and bad points. The welfare state is expensive and funding is now a major issue to deal with as our population ages. The government today must find a way to pay for the care industry which is spiraling out of control as patient expect lower waiting lists and excellent service without having to raise taxes. Health care is a very complicated issue to deal with as many other facets of life affects the health of our country such as poverty, demographics, the economy and politics.

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