Chapter 7. Healthcare policy and organizational change
Gillian Olumide and Hannah Cooke
▪ The development of the welfare state
▪ The development of the NHS
▪ Contemporary issues in UK healthcare
Introduction
This chapter will put present-day healthcare into context by looking at the changing nature of UK approaches to healthcare. Social policy has reflected changing political and economic circumstances and the prevailing political debates of the time. We have discussed the theme of inequality in previous chapters and have noted that some groups in society are disadvantaged and lacking in power and influence. These inequalities of power and resources have also shaped the policy process with more powerful groups often more able to get their voices heard and to shape the direction of policy.
Nurses care for some of the most vulnerable members of society so nurses’ work is profoundly affected by social policies over which nurses often have very little influence. Nurses also need to understand the policy context in which they work in order to understand how nursing is being shaped and directed. Only through greater understanding of the policy process can nurses begin to have a voice in the future direction of nursing.
In this chapter, we will first consider key concepts in welfare then we look at different political belief systems and what they say about welfare. We then consider the development of the welfare state before considering the origins and development of the National Health Service.
Key concepts in the provision of welfare
EQUALITY
Equality can take many forms. A concern with legal and political equality has involved issues such as voting rights. We are concerned here with social equality which relates to the distribution of social goods such as education and health services.
Political beliefs about equality vary. Egalitarianism involves a commitment to equality in its purest form and underlies some religious and political ideologies such as socialism. Egalitarianism involves some attempt to achieve equality of outcome – for example in life expectancy or health status. Egalitarianism appeals to ideas of brotherhood, sisterhood and social solidarity (Blakemore 2003). Social policy theorists who have advocated egalitarianism include R H Tawney (1931) and T H Marshall (1963). These theorists believed that a commitment to egalitarianism would create a society in which everyone felt valued and that this would reduce social problems such as crime and mental illness. Authors such as Marshall saw the unfettered free market as socially destructive (Barry 1990). According to Marshall:
‘What matters is that there is a general enrichment of the concrete substance of a civilized life, a general reduction of risk and insecurity, an equalization between the more and less fortunate at all levels’. T H Marshall (1963: 107)
Criticisms of egalitarianism tend to focus on differences between people arguing that egalitarianism is either unachievable or undesirable. Critics believe that egalitarianism creates unwanted uniformity. Critics of egalitarianism thus offer market ideas such as choice as an alternative value (Barry 1990). Whilst there may be general consensus that complete equality of outcome is unachievable, ideological differences centre on the question of whether it remains a desirable goal; should we try to reduce inequalities in society or accept that in a competitive society there are winners and losers?
A second version of equality is the idea of equity. This idea modifies the idea of equality in ways that are intended to take account of the differences between people. Thus, instead of equality of outcome we have ideas of fairness and justice (Blakemore 2003). Equitable policies tend to favour improving access and delivering targeted rather than universal services based on individual needs and circumstances. This does however, depend heavily on having a fair and accurate assessment of needs and this is where policies based on equity often have difficulties since concepts of need are often disputed.
Proponents of market approaches to welfare tend to favour equality of opportunity rather than equality of outcome. This involves removing barriers to access so that everyone has the same chance at the outset; the idea of fair competition. This has frequently involved a legislative framework establishing formal equality such as the Disability Discrimination Acts of 1995 and 2005 discussed in Chapter 14. Political differences tend to centre on whether establishing formal equality of opportunity is enough on its own. Arguments depend on whether a ‘level playing field’ really exists and thus on the extent to which structured inequalities limit individual’s life chances as we saw in Chapter 5 and Chapter 6. Critics argue that positive action is also needed, for example, tackling prejudice and unfair practices and helping disadvantaged groups to access services (Lister 2001).
HUMAN NEEDS
We said in our discussion of equity that some notion of need often underpins ideas about the equitable distribution of resources. We also noted that conflicts can arise about the assessment of human need. Of particular interest to healthcare professionals is the distinction between needs, wants and desires. Take for example the provision of fertility treatment – is having a child something that we should consider as a need or as a desire?
There are a number of different theories of human need. The one most familiar to nurses is the psychologist Maslow’s (1943) hierarchy of need. His hierarchy is a theory of human motivation. He believed that needs were arranged in a hierarchy with physiological and safety needs at the base and ‘self actualization’ at the pinnacle. He argued that lower needs had to be satisfied for higher ones to become motivators. Maslow’s theory has many critics. Arguments have centred on the limited evidence base for his theory. It has also been criticized for basing ideas about human nature on US society and culture.
A more recent theory of particular relevance to welfare policy has been Doyal and Gough’s (1991)theory of universal human needs. Doyal and Gough criticize the idea of a hierarchy of needs and say that there are two basic and universal needs – health and autonomy. Following on from this premise, they say that it is relatively easy to establish a list of universal human needs on the basis that any society will need to provide these in order to provide for these two basic needs. Their list is as follows:
▪ Nutritious food and clean water
▪ Protective housing
▪ A non-hazardous work environment
▪ A non-hazardous physical environment
▪ Appropriate healthcare
▪ Security in childhood
▪ Significant primary relationships
▪ Physical security
▪ Economic security
▪ Appropriate education
▪ Safe birth control and child bearing.
Doyal and Gough say that their list is based on research evidence and that governments should be judged on how well they provide for the needs of their people. They suggest that being deprived of any of the needs that they describe will lead to measurable harm. Their theory has led to comparative research to judge how well different countries provide for the needs of their citizens and their work has been influential in the study of health inequalities.
HUMAN RIGHTS
Another important set of values which have influenced health policy are values concerned with human freedom and human rights. T H Marshall made a classic distinction between civil, political and social rights. Marshall believed (based on the history of the UK) that as society developed these rights should develop (Marshall 1950).
▪ Civil rights – rights under the law such as freedom from arbitrary arrest, right to a fair trial, freedom of speech, freedom to join groups such as trade unions
▪ Political rights – right to vote and to join political parties, right to political repre-sentation
▪ Social rights – rights to welfare and health such as a right to receive healthcare, a right to have access to clean water.
Debates about rights have involved arguments about specific groups whose access to rights has been unequal, for example women, ethnic minorities and people with disabilities. More recently, the ‘animal rights’ movement has tried to extend the notion of rights to include the animal kingdom. Political differences have centred on the relative importance of civil, political and social rights with the existence of social rights being the most contentious issue. Since social rights have been eroded by neo-liberalism Marshall’s theories have been challenged by some theorists while others believe that they are still worth defending (Bulmer & Rees 1996).
A related concept is that of citizenship. Citizenship involves membership of a society which confers both rights and responsibilities. The definition of citizenship can both include and exclude people. Debates about citizenship have often concerned groups that have been excluded or denied some of their rights such as women, people with disabilities and migrant labourers (Lister 1997).
There has also been concern over the nature of the rights that citizens should enjoy. The strong version (associated with social democracy) says that citizens should have social rights such as healthcare and relief from poverty. The weak version confines citizenship rights to civil and political rights.
Political ideologies influencing welfare
Policies that attempt to meet the health and welfare needs of the population depend on underlying political beliefs. It is important to be able to distinguish between some of these beliefs as the policy that flows from them sets out to achieve different social outcomes. The following sections present key political approaches to welfare which have been influential during the history of the welfare state. Differences in political positions tend to reflect alternative views about how society should be managed and the needs of the people catered for. Beliefs about values such as equality and human rights and about how and why these will be achieved vary considerably between political positions. There are other important differences such as philosophies concerning the role and size of the state and the extent of its responsibilities. Even state provision of free nursing services is a point of political debate.
SOCIAL DEMOCRACY
The thinking behind the welfare legislation of the 1940s was broadly social democratic. Social democracy in the UK was influenced by Fabian socialism which argued that social justice could be achieved by an enlarged (welfare) state for the benefit of all citizens rather than through the revolutionary changes advocated by many Marxists. Another philosophical contribution to the origins of the welfare state was ethical socialism, which had Christian roots and provided a critique of the social inequality produced by industrial capitalism. Thinkers, such as Tawney (1931) saw the exploitation of labour as an indignity that needed to be addressed to achieve a more equal and just society.
The idea that the state should be involved in protecting and providing for the welfare of its citizens is sometimes called a collectivist approach, indicating that the welfare of all is the responsibility of all. Collectivists tended to argue for the reduction of inequalities through the redistribution of resources (see Chapter 5 and Chapter 6). The welfare state, funded from taxes, was one important means of achieving this aim. Higher earners are expected to pay more in taxes and make a greater contribution to welfare services than those with lower incomes.
CONSERVATISM
Conservatism stems from Edmund Burke’s ‘two principles of conservation and correction’. ([1790] 1968). In this thinking, society should preserve the traditions of the past whilst improving the life of the nation. According to Fitzpatrick (2005), Conservatism focuses on the fragility of social order seeing human society as a ‘rudderless ship on a harbourless ocean’. The most important question for government then becomes how to avoid ‘rocking the boat’. Conservatism therefore values the lessons of experience and advocates incremental rather than radical change. Thus it has tended to support the status quo and as a result has often been seen as associated with the defence of privilege and the perpetuation of social inequality.
However, Conservatism has adapted to social changes such as the Industrial Revolution and the creation of the welfare state and is not without a reforming element. Disraeli (Conservative prime minister during the 1860s and 1870s) was a notable social reformer who formulated ‘one-nation conservatism’ which was committed to national unity and the building of social consensus.
Collectivist views had gained support during the early twentieth century but the Conservative Party opposed many of the Beveridge proposals for welfare reform, leading to its defeat in the 1945 election. Subsequently, the Conservative Prime Minister, Harold Macmillan, showed during the 1950s, that a Conservative government could adapt to the existence of the welfare state. Health and housing services in particular were improved and extended under conservatism. This was a revival of ‘one nation conservatism’ which held to a vision of a society which, while not aspiring to equality, acknowledged the inter-connectedness of all citizens. The Conservative leader, David Cameron, has recently tried to re-invent some of the ideas of ‘one nation conservatism’.
NEO-LIBERALISM
In 1976, when Margaret Thatcher became Conservative party leader, anti-collectivist opinions within conservatism came to the fore and the party turned its back on ‘one nation conservatism’. Traditional conservatism was challenged by neo-liberal (or ‘new Right’) ideas. Briefly, these ideas concerned a determination to ‘roll back the state’, reduce the burden of taxation and promote ‘freedom’ and ‘efficiency’ through the introduction of market forces into public services. Economic liberalism was, however, accompanied by a commitment to social conservatism with a stated aim to restore ‘Victorian values’ of individualism and self help and to strengthen ‘family values’ (Clarke & Newman 1997).
We discussed the idea of the market in Chapter 4. The ‘new Right’ believe in the ability of free markets to organize choices about welfare far more effectively than the state. The political instincts of the ‘new Right’ have been to decrease state intervention in private matters in order to avoid a ‘nanny state’, which they suggest limits freedom and creates dependency. Thus in Hayek’s (1944) famous words the welfare state is regarded as the ‘road to serfdom’. Neo-liberal governments have tended to reduce taxes, limit public spending and introduce charges for welfare services. They have emphasized the use of market mechanisms in the provision of public services arguing that these promote freedom of choice. They have promoted a ‘mixed economy’ of welfare services in which state services compete with charitable and private providers. They argue that ‘managed competition’ encourages providers of services to become more efficient in order to compete for business.
THE ‘THIRD WAY’
Social democracy envisaged a welfare state as achieving greater equality through state sponsored collectivist policies. By contrast the ‘Third Way’ initiated by Clinton’s New Democrats in 1992 and promoted by the ‘New Labour’ administration has dwelt more on removing barriers to individual achievement (equal opportunities) than on achieving equality of outcomes or a more even distribution of resources. Giddens (1998) suggested a new approach to welfare, which enabled people to make their own estimations of need rather than having these defined by the state. The ‘Third Way’ marked a drift away from a concern with social inequalities. Instead, the ‘Third Way’ has been preoccupied with ‘social exclusion’, a term much used by New Labour which tends to refer to a lack of ability or willingness to participate in the labour market (Lister 1998). The emphasis has thus moved away from equality of rights towards an equality of obligations (Fitzpatrick 2005) with an attempt to extend the obligation to participate in the labour market to, for example, single parents and people with disabilities.
Powell (2000) points to the fact that terms, such as ‘welfare’ are being given new meanings under New Labour’s administration. The older understanding of welfare as a safety net for all citizens is transformed into a situation where citizens may expect ‘a hand up not a hand out’. Echoing many of the ideas of the neo-liberals, education, good health, the acquisition of skills and hard work are seen as the main routes away from poverty and exclusion.
‘Third Way’ politicians have embraced the use of market mechanisms in the provision of welfare services. There is, however, more emphasis on state regulation of managed markets than under neo-liberal Conservative governments (Cutler & Waine 2000). For example, new Labour’s ‘modernization’ of the NHS has emphasized on the one hand competition and choice but on the other hand, has introduced a highly centralized framework of regulation and performance targets. Although there has been disagreement as to where the balance lies, many critics have argued that the ‘Third Way’ lies closer to neo-liberal approaches than to social democracy (Baggott 2004).
The creation of the welfare state
Before considering the creation of the welfare state after the Second World War, we outline the provision of welfare prior to this period. According to Blakemore (2003) there are some enduring themes in welfare provision. Furthermore, historical approaches to welfare, such as the ‘poor laws’ and the workhouse have had a lasting impact on cultural attitudes to welfare. Laws to help the poor in Britain dated back to the Tudor period, as we noted in Chapter 6. However, the 1834 Poor Law Reform Act marked a radical break with the past. The Act associated ‘pauperism’ with shame and stigma and introduced the principle of ‘less eligibility’, which decreed that welfare conditions should be worse than the worst paid job available in the labour market. This led to the creation of the ‘workhouse test’ in which ‘paupers’ were expected to forego their liberty and civil rights and enter an institution if they wished to receive relief. This system of ‘indoor relief’ set up the conditions for widespread institutionalization of problem populations during the nineteenth century as we discussed in Chapter 4.
The legacy of the Poor Law remained until the start of the Second World War, although poor law institutions had been handed over to local authority control during the 1920s. Arguably, the cultural legacy of the poor law remains today with poverty and welfare dependency still attracting shame and stigma even when associated with unavoidable causes such as disability and chronic illness.
In the UK, Lord Beveridge and a small committee provided, in 1942, the blueprint for a comprehensive system of welfare organized by the state and paid for through taxation. Beveridge’s original brief was to regularize the patchy social insurance system that had grown up to provide limited welfare benefits to some sections of the population. The Committee however delivered a much bolder plan which alarmed the serving Conservative administration because of its cost implication. The proposal included welfare services for all citizens and a national health service which served the entire population and which was free at the point of delivery. This plan for state sponsored welfare was taken up by the post war Labour Government and implemented in 1948.
Areas envisaged in this post-war settlement as being in need of attention, referred to by Beveridge as the five giant social evils (Timmins 2001), were ignorance, want, idleness, disease, squalor. In response, education, employment, income maintenance, housing and health became the concern of the state at local and national levels. These are also now routinely acknowledged to be amongst the key social determinants of health.
‘The plan for social security is put forward as part of a general programme of social policy. It is only part of an attack upon the 5 giant evils: upon physical want, with which it is directly concerned; upon disease which often causes that want and brings many other troubles in its train; upon ignorance which no democracy can afford amongst its citizens; upon squalor which arises mainly through the haphazarddistribution of industry and population; and upon idleness which destroys wealth and corrupts men, whether they are well fed or not, when they are idle’. (From theBeveridge Report 1942)
The development of the national health service
HEALTHCARE BEFORE THE NHS
Prior to the development of the NHS, healthcare was provided by a mixture of institutions. Self-governing ‘voluntary hospitals’ often founded by charitable subscription existed alongside municipal hospitals run by local authorities. Many of the latter were remnants of the old workhouse system although some enlightened local authorities had developed new hospital services. A social insurance system founded in 1911 gave workers access to GP services but their families were not covered by this system. Free care was not universally available and cost was a barrier to treatment for many people. In the inter-war years, there was increasing concern about the chaotic nature of UK health services as UK health indicators began to lag behind other countries (Webster 2002). There was a recruitment crisis in nursing due to poor conditions, low pay and long hours. An influential survey in 1939 found that there was a ‘chaotic jumble’ of services with no overall standards, too many services in some places and huge gaps in others (Herbert 1939).
THE CREATION OF THE NHS
At the outbreak of the Second World War, there was enormous concern about the ability of Britain’s disorganized healthcare system to cope with wartime casualties. The Emergency Medical Service was set up by the government to coordinate and plan wartime healthcare. The experience of war led not only to the promise of new social welfare services offering a better future after the war as outlined in the Beveridge report. It also led to an appreciation of the benefits of better coordination and planning of healthcare services at both a regional and national level.
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