Policy Framework Development
In this essay, I will discuss the welfare state since World War II and how it has impacted society in England and Wales. In addition, I will discuss the importance of social policy, how it was developed and the four most frequently used approaches. The ideas behind these approaches will be explained and some examples of such policies in different fields will be provided. Overall, evidence will be provided on how social policy became educational discipline in its own right.
The origins of the National Health Service
One of the most drastic social policies put into action in England and Wales has been the implementation of free medical treatment for all, through the National Health Service. According to Alcock (2008), illness was very common and health care expensive before the National Health Service (NHS) came into existence in 1948. Poor housing, overcrowding, poor sanitation, malnutrition and lack of education were common, enabling the spread of infectious diseases such as tuberculosis. Life expectancy was considerably lower, at a mere 60 years. During the 19th century, health care was provided through the workhouse, or municipal and voluntary hospitals. The rich were often treated in their own homes or in a private practice. A lady Almoner was responsible for carrying out a means test, which determined who got medical treatment, she was also responsible for approaching charities for funding. (Alcock, 2008)
The ideology behind the development of the NHS was to put an end to ignorance, squalor, disease and poverty, by ensuring health care was available to all. This included free treatments for all, a family benefit scheme and full employment. Although some saw it as a politically risky move, Prime Minister Churchill gave his full backing for the NHS in 1943, thus starting the reform towards free health care. As Bochel reports:
“During 1944, White Paper proposing a national health service, and the election of a Labour Government in 1945 made the establishment of a NHS almost certain. The necessary legislation was passed in the 1946 National Health Service Act.” (Bochel, 2009, p. 332).
Finally, the NHS became a reality on July 5th 1948. It was an enormous achievement but due to the significant investment in time, money and resources, it was not met without opposition- this was a time when there were food and fuel shortages, as well as a dollar economic crisis. However, the general public wanted the new service to succeed, and as such Britain became the first country in Western Europe to offer free medical service, funded through the general taxation system. According to Bevan:
“It was based on three core principles which include; it meets the needs of everyone, to be free at the point of delivery and it to be based on clinical needs, not ability to pay.” (National Health Service History, 2012).
These core principles have remained the same since the creation of the NHS (Bochel, 2009,p. 332).
However, free health care as provided by the NHS proved to be very expensive, with the drug bill increasing from ?13 million to ?41 million within the first two years of its creation. Additionally, as medicine progressed as a science, new technologies and methods increased the cost of the NHS from ?200 million to ?300 million. The provision of free health care for all led to excess demand, adding pressure to the already limited medical resources. The Government was reluctant to cover the excess cost, as it needed to invest in other sectors, such as education. As a result, charges for certain services, such as spectacles and dentures, as well as for prescriptions were implemented (Alcock2008).
Neo-liberal ideology and the NHS
In 1979, when the NHS had been in place for several decades, a Neo Liberal Government was elected, with little sympathy for the state provision of welfare and the high level of expenditure associated with it (Bochel, 2009, p. 332). Neo-liberal ideology supports the reorganization of the financial and organizational aspects of healthcare services worldwide, based on the argument that the then-existing health systems had failed. According to the recommendation report in 1983, four major problems of health systems globally were: i) misallocation of resources; ii) inequity of accessing care; iii) inefficiency; and iv) exploding costs. It was claimed that government hospitals and clinics were often inefficient, suffering from highly centralised decision-making, wide fluctuations in allocations, and poor motivation of workers (Alcock, 2008). Quality of care was also low, patient waiting times were long and medical consultations were short, misdiagnosis and inappropriate treatment were common. Also, the public sector had suffered from serious shortages of medical drugs and equipment, and the purchasing of brand-name pharmaceuticals instead of generic drugs was one of the main reasons for wasting the money spent on health (Navarro, 2007). Private providers were more technically efficient and offer a service that was perceived to be of higher quality.
Examples of policies implemented by the Neo-Liberal Government were those based on cost-effectiveness. Cost-effectiveness was presented as the main tool for choosing among possible health interventions for specific health problems. Disability-adjusted life years (DALYs) were used to measure the burden of disease and thus allowing comparisons between specific health problems. Greater reliance on the private sector to deliver clinical services was encouraged, with the expectation that it would raise efficiency. It was suggested that Governments should privatise the healthcare services, by selling the public goods and services, buying the services from the private sector, and supporting the private sector with subsidies. In order to increase efficiency, unnecessary legal and administrative barriers faced by private doctors and pharmacies would need to be removed.
Neoliberal policies in healthcare were heavily criticised as they reportedly misdiagnosed the problems and its treatment, leading to a situation worse than it was before the policies were implemented. Shrinking from welfare state to minimum liberal state, retreating from most of the public services and letting the area to irrationality of market dynamics is making pharmaceutical, medical technology, insurance, and law companies the lead actors. It has been claimed that a system providing services according ability-to-pay rather than healthcare need, ensures decreased availability and accessibility to services” (Danis et al., 2008; Janes et al., 2006; Unger et al, 2008).
New Labour and the NHS
In 1997, the New Labour Government was elected, with a main focus to make a significant improvement on peoples’ health. This was expected to be done by rebuilding the health services within the NHS through “decentralizing of power and decision-making to local health trusts”. Decentralising was important in order to achieve increased responsiveness to local health needs by widening patient choice, and promoting organizational efficiency. The underlying premise was that decentralization would shorten the bureaucratic hierarchical structure and allow flexibility for local trust managers and health professionals- thus improving organizational performance from the ‘bottom-up’ (Crinson, 2009 :p 139). In 1997 the Government put forward its plans in the White Paper: “The New NHS: Modern, Dependable” (Blakemore 2003:p 172). The objective was to reduce bureaucratic control from the centre and restore autonomy to health professionals within the NHS. At the same time, the Government was determined to limit public expenditure by looking at what was already put in place by the previous government. One of the new Labour objectives was to reduce the number of people on the treatment waiting list by offering patients greater choice of provider at the point of inpatient referral. This was put in place from January 2006 onwards, where patients have been offered a choice of at least four hospitals when referred for treatment by their general practitioner. In addition, a new inpatient booking system was put in place, where patients themselves could book their place and time of treatment (Adam, 2006). In 1998, health inequality targets were included in the public service agreements with local government and cross-department machinery was created to follow up a ‘Programme of Actions’, which had the general aim to reduce inequality in terms of life expectancy at birth, and to reduce the infant mortality rate by 10 per cent by 2010 (Glennerster, 2007 : p 253).
Examples of health care policies implemented by New Labour are:
Maximum waiting times for in-patient treatment: six months by 2005 and three months by 2008;
Patients able to see a primary care practitioner within twenty-four hours and a GP within forty- eight hours;
Maximum waiting time of four-hours in emergency rooms;
Plans to improve cancer treatment and health inequalities.
In addition, in order to improve efficiency, two bodies were set up to give advice and push for more consistent and effective clinical standards in determining the cost of new drugs and procedures. This was the National Institute for Clinical Excellence (NICE) (Glennerster,2007 : p 250).
However, as argued by Peckham and colleagues (year?), the decentralization of the NHS had mixed results. They note that the process of decentralization was not clear and that there were contradictions, reflecting a simultaneous process of centralization and decentralization, in which local performance indicators were centrally-set. If achieved, this resulted in increased financial and managerial autonomy. However, there was some supportive evidence that decentralization had improved patients’ health outcome, as well as improved efficiency in coordination and communication processes (Crinson, 2009 : p 140). The Government at the time met its target for treatment waiting lists by 2000- the number of people on the waiting list had fallen by 150,000. However, one main criticism came from the doctors, nurses and other health professionals where they were the ones dealing with prioritizing patients based on medical need, whilst having to explain to other anxious and angry patients why their treatment is delayed (Crinson, 2009).
Coalition Government and the NHS
In 2010, the newly established Coalition Government published the NHS White Paper ‘Equity and Excellence: Liberating the NHS policy’, prepared by the Department of Health. This policy included important changes compared to those proposed by the previous Government, and reflected the aims of the Coalition’s five year plan. Some of the proposed changes include: i) responsibility for commissioning of NHS services shifted to GPs, as the Primary Care Trusts and Strategic Health Authorities were dissolved, and ii) Foundation Trust status granted to all hospitals, ensuring increased autonomy and decision-making power. These reforms were part of the Coalition’s broader goal to give more power to local communities and empower GPs. By way of estimation, it is expected that this cost to about 45% for the NHS management. Strengthening of the NHS Foundation Trusts in order for these Trusts to provide financial regulation for all NHS services was another objective of the reform. An independent NHS board was set up, with the aim to lead and oversee specialised care and GP commissioning respectively. The objectives behind the Coalition Government’s plans was to increase health spending in real terms for each year of Parliament, with full awareness that this would impact the spending in other areas. The Coalition Government still maintained Beverage idea that all health care should be free and available to everybody at the point of delivery, instead of based on the ability to pay. It was expected that this approach would improve standards, support professional responsibility, deliver better value for money and as such create a healthier nation.
Although the Prime Minister rectified it in his speech, the Government failed to provide a clear account of the shortcomings of the NHS and its challenges. The preparation of the White Paper, which was to pass the coalition committee’s examination, saw more compromises. The elimination of PCTs was not foretold but the conservatives would make PCTs remain as the statutory commissioning authority responsible for public health despite their commitment to devolving real budgets to GPs. It was rumoured that the Liberal Democrats policy of elected representatives to PCTs appear weak. The compromise was to give greater responsibility for public health to local authorities and eliminate PCTs. This resulted in the formation of the GP commissioning consortia and the Health and Wellbeing Boards. Despite concerns raised by stakeholders, the proposals saw just a few changes. Maybe we can call it a missed chance in retrospect.
In conclusion, it can be argued that without the NHS coming to force when it did at such a dire time after the Second World War, the already high mortality rates would have continued to rise. The NHS was vital in changing peoples’ lives in England and Wales and around the world. The system was designed meet everyone needs, regardless of financial abilities and without discrimination. Many changes have taken place since the birth of the NHS in 1948. Four different Governments adapted the NHS with their policies and legislation. However, throughout its evolution, the NHS still provides healthcare free of charge, as was intended from its conception.
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