This essay is a discussion of how Social Policy had an impact to the National Health Service (NHS); the essay will pace the discussion in the context of some of the economic, political and social concepts that influence the development of social policy in the NHS. It also discusses the impact of the social policies in relation to social exclusion, inequality and/or poverty. While evaluating the effectiveness of these policies, it will explore the relationships among the different agencies involved in social welfare provision.
Social policy is aimed to improve human welfare and meet human needs (Ken 2007 pg 1). During the 1942 Beveridge report on social security, it was recommended that a comprehensive national service should be developed to combat ill health after the Second World War. In 1944 proposals were brought up for the development of the NHS, legislation was passed in 1946 and in 1948 NHS started its operation after the National Health Act (1946). It provided a comprehensive service to the whole population at a relatively low cost. It was to be run nationally and mainly financed from taxation and a small token from National Insurance Fund and was substantially free at the point of delivery Howard (2000). All citizens had to be registered with a family doctor in order to receive free treatment for miner illness and be referred on to hospitals for those conditions that the General Practitioner (GP) could not treat. The NHS had popular support in the 1940's and in 1944 Henry Willink the conservative Minister of health, described the health proposals as representing the: “very root of national vigour and national enterprise...the biggest single advance ever made in this country”. Webster (1988), Howard (2000 pg98).
Despite its achievements and popularity since the 1980's, the NHS has come under increasing pressure and strain from the conservative governments which have seen it as a burden on the economy. It has come under intensive criticism for being professionally dominated, unresponsive to consumers and internally inefficient and ineffective in the use of resources. And as a result in the 1990's the NHS and community Act come in to force and introduced changes that have been seen as the most radical since the 1946 Act that created the service. Though the NHS remained tax funded at the point of delivery, this Act recommended the introduction of an internal or quasi market and the introduction of a split of the NHS budget between those who purchased the services for their population and those who provide the services. The command and control model of the NHS with the Top-down directives was replaced by a system where the local purchasers negotiated contracts with the providers also emphasis was placed on introduction of audit system and better monitoring of performance. Purchasers (the districts) determined what services they wanted and who they should be bought. This means that the trading costs were a priority for the purchasers than the quality of the services. The aim of the conservative government in introducing the markets was to drive up standards and increase accountability (Enthoven, 1985).
The conservative government came into power in May 1979 strongly influenced by the political philosophy of the New Right government policy in general strongly promoted business and private enterprise and sought to discourage individuals and families from succumbing to ‘welfare dependency'. Reliance on the market (not the state), increased the competition and to a greater choice for individuals- consumer sovereignty- were the principles which underpinned a plethora of policies during the 1980s and 1990s. Individualism was lauded over collectivism Dorey (2005:p.104). Thatcher applied policies of Milton Friedman's monetarism (1980) that aimed at controlling inflation by reducing government borrowing and subsidise industries through privatisation. This involved selling government funded services to companies and individuals who had money to invest Jenkins, (1987). The main aim was to raise money and pay off the government debts and to improve efficiency of nationalised industries. The National Health Service was not privatised but was reorganised into parts, the medical which was dealt with by the government while the ancillary was privatised to competitive tenders from private companies (cheap bidders win). It was assumed that competition would increase efficiency, reduce costs, create social justice in order for everybody to get equal treatment and discipline medical behaviour. But all this did not work out as planned. For example hospitals were not properly cleaned leading to an increase of infections like Methicillin Resistant Staphylococcus Aureus skin infection (MRSA) and Clostridium Difficile (CDF).
It can be argued that the Thatcher's politically influenced policy reforms were aiming at privatisation through the creation of market which is contrary to the foundation principles of NHS which are free at the point of delivery. This argument leads one to question whether Thatcher had prepared the NHS for these radical reforms. But also one wonders if the government had planned how the poor would access NHS services without being excluded on financial merit.
King (2005) asserts that there was no immediate overhaul of the NHS in order to render it compatible with and complementary to these new values as it encouraged greater use of private health care while from 1983, health authorities were required to contract out domestic, catering and laundering service. In relation to poverty and inequality, it can be argued that this policy created unemployment for those who lost their jobs during the privatisation and also those who could not afford to pay for private health care; they were excluded from accessing the services.
However, Haus argues that Margaret Thatcher saved the British economy by bringing both the inflation and unemployment under control and by creating a more dynamic private sector they called a third way that combines the best aspects of the socialist commitment to equality and market economy. But to her opponents, Haus says that they viewed her policies as new problems and exacerbated existing ones by widening the gap between rich and the poor and by allowing public services to deteriorate (Haus 2009).
Much as the privatisation policy appears controversial from Haus perspective, the element of controlling inflation and saving the British economy from the 1980's depreciation implies that there were economic drivers that influenced Margaret Thatcher to reform the policies. This argument is supported by Alcock. He states that “social policy development is also closely dependent upon the economic structure of the society and upon the economic growth within it” (Alcock's 2008: p.198).
One of the new Labour's main objectives when elected in 1997 was to make significant improvement in the NHS and in line with that the NHS was to be rebuilt. The government put forward its plans in a White paper. (The new NHS Morden dependable Department of Health 1997).
Following the publication of the white paper on the NHS in 1997 and a various other consultation document, wide ranging health reforms were discussed which led to the Heath Act 1999.
This Act brought key changes in the NHS. The internal markets which were introduced by the Thatcher government in the 1990's were replaced by a new policy which encouraged co-operation and partnership between health services and between the NHS social services and other care providers.
In 2001 primary care groups were established in every area of England with the aim of running the health services. The primary care groups were formed by local groups of doctors and nurses, theses organisations were to oversee the delivery of primary health care to the local community through family doctors. They also directed resources available to the NHS trust and other health service organisation (Blackmoore, 2003).
The health Act 1999 together with the health Act 2001 led to the introduction of the Primary Care Trusts which were meant to run health and social service jointly. According to Downey ( 2001 p 34) “ the health and social Act of 2001 led to a radical shake up of the social service never seen in three decades”. The Labour government under Tony Blair made significant changes to the doctors' contracts due to economic factors, mainly limitations of the capitation system in GP funding. Instead it introduced what was termed as modern contracts for GPs and hospital doctors. The contracts were to be quality based and doctors were paid on condition upon reaching certain performance targets. GPs were required to meet specified improvements in preventative care as well as quality of their services to patients. The General Practitioners (GPs) were budgeted and were expected to work within those budgets to meet the needs of their patients. They were rewarded if they managed to work within their budgets and given additional money for running health promotional clinics. They were to shop around for the cheapest provider for their patients. However as they were reluctant to accept patients' who would drain on their budgets thus care for the people who needed it most in most cases suffer. Shaun et al (2001).
Inspection of the health service was introduced together with the central regulation. This meant that the health care standards and health service delivery were to be monitored by an organisation known as the national institute for clinical excellence. This body was to decide which drugs and new treatments are to be available to patients ‘free' on the NHS.
In line with the above, another regulatory body was set up. It was known as the Commission for Health Improvement (CHI). This body was to inspect the standards of hospital and primary care. In fact this body was meant to act as Ofsted in providing league tables of schools and colleges but for CHI it created hospital performance league tables by publishing patients' survival rates after various hospitals and operations.
In contrast however, the publication of league tables with ranking of performance, create negative impact to the primary care trusts and hospital located at the bottom of the table that they provide worst services. It also creates negative impact on the public trust and professional moral because staff may be demoralised in reaching its maximum potential for better services if their hospital is considered to be under performing. Again the use of league tables do not really reflect the quality of hospital treatment, because they include a small number of key clinical areas and doubt go into detail about the process of care. What they really show is the effectiveness of trust's management team rather than standard of clinical care. More so, even if patients are aware of their local hospital performance, they have no choice about where to get better treatment because hospital referrals are decided by GPs.
In 1997, the labour government under Blair recommended a welfare review. However, there was no attempt to reverse the changes made by Thatcher and accepted that there can be no return to the “Golden Age”. The main welfare provision that Labour introduced is called WELFARE TO WORK, A NEW DEAL. It was aimed at helping groups especially young, lone parents and long-term unemployed who rely on benefits, to find work and support themselves. Labour's approach was to find a third way between the “Golden Age” welfare state and the conservative changes. The government introduced a minimum wage to make-work more attractive than claiming benefits. The Blair government did a lot to improve the NHS and in 2002 Blair staked the future of his government to improve the NHS.
The distribution of wealth in Britain saw a number of arguments, which were about equality, and the impact of welfare state on various sectors in society.
Capitalist do not fund welfare systems as the workers pay for it through direct taxation; they pay for their own health. Poor people carry far more of the tax burden in real terms than the wealthy because the cost of the indirect tax such as VAT on items such as beer and cigarettes take a large portion of their income (Shaun et al, 2000) the wealthy benefits more the welfare state than do the poor such as tax relief on mortgages.
Socialist. The socialists argue that the welfare of individuals is the responsibility of the state. They argue for redistribution of income through taxation so that the rich can fund the welfare of the poor. They wish to change the structure of the society to benefit the poor and bridge the gap between rich and poor. The socialists argue in favour of universal access to welfare and are opposed to targeting benefit.
Liberals. They argue that welfare is needed to support capitalism and to support the poor. Writers such as Anthony Giddens, suggest that the state cannot leave some of the problems to market forces to solve because these problems are too big or too complicated .The liberals sort out problems as they arise without either looking for them or allowing any rigidly held views influencing common sense views of the events.
In conclusion welfare state developed due to a number of factors contributing poverty, sickness, high levels of unemployment after the Second World War. The recommendations of the Beveridge report about the five evil ‘giants' influenced the government to introduce the welfare state and to the subsequent changes to the NHS.