The Welfare State

1. The Welfare State Welfare State

2. Before Beveridge Before Beveridge and after Beveridge (1942) Wrong to take Beveridge's claims of "revolutionary change" at face value. Britain already had a system of insurance against illness and unemployment, although it was imperfect and incomplete, and left some sections of the population relatively unprotected. The "New Poor Law" of 1834 restricted poor relief to people who were absolutely unable to fend for themselves: the very sick and the very old. Anyone else who fell on seriously hard times had to go to the "workhouse". Workhouses were tough, unpleasant places were the very poor had to work hard to earn their (often sub-standard) keep. People hated them. Welfare State

3. Before Beveridge The Liberal government of the early 20th century introduced a system of National Insurance in 1911. Workers contributed to a system of national insurance to protect tham against sickness and unemployment. After the First World War, in an attempt to provide "homes fit for heroes", the government undertook to build "council houses" for working-class families living on low incomes (1919). Welfare State

4. Beveridge In 1940 Winston Churchill became Prime Minister of a coalition government. Labour insisted that a report should be produced into "Social Insurance and Allied Services". Sir William Beveridge was asked to produce the report. It was published in December 1942. Beveridge had ensured that it was given great publicity. It sold in large numbers. It is best known for its introduction, and especially for Beveridge's plea that there should be a comprehensive attempt to deal with a wide range of social problems (the "five giants"). Welfare State

5. Beveridge These "five giants" were Want Disease Ignorance Squalor Idleness Welfare State

6. Beveridge Want = poverty Disease (health care) Ignorance (education) Squalor = poor housing Idleness = unemployment Welfare State

7. Welfare State

8. Beveridge Lord Beveridge, photograph by Yousuf Karsh. Camera Press, "Beveridge, William Henry Beveridge, 1st Baron." Encyclopædia Britannica. 2005. www.britannica.com Welfare State

9. After Beveridge Many in the Labour party called for "Beveridge now!" The Conservatives showed less enthusiasm, and although Churchill said that he found welfare to be a praiseworthy objective, he said he would make no promises. There would be other priorities after the war. This was undoubtedly one of the reasons he lost the 1945 general election. Welfare State

10. After Beveridge Family Allowances were introduced before the end of the war, in 1945. The Butler Education Act, 1944, introduced free secondary education for all (up to the age of 15) (see next lecture). The rest of the legislation underlying the Welfare State was introduced during the 1945-1951 Labour government under Clement Attlee: National Insurance Act 1946 (social security in return for contributions) National Health Service Act 1946: free medical care "from the cradle to the grave" Welfare State

11. After Beveridge National Health Service General Practitioners (GPs) were paid a "capitation fee" for providing health care for the people under their responsibility (their "panel"). Health care was "free at the point of contact". Patients did not pay for appointments with a doctor or a dentist, for drugs, for hospital care, for glasses ... Welfare State

12. After Beveridge National Assistance Act 1948: "safety net" protection for people who were not covered by National Insurance. In 1950 Clement Attlee was able to claim that "the foundation of the Welfare State have been very well and truly laid" (quoted Les clés ... p. 179) Welfare State

13. Welfare State The Welfare State soon ran into financial difficulties, and charges were introduced in the early 1950s for prescriptions and for spectacles and dentures ... It had been assumed that spending on health care would gradually fall, as the "backlog" of poor health was gradually dealt with. What happened was quite the opposite. Better technology, increased expectations, longer life expectancy ... all conspired to drive health care spending up. Welfare State

14. Welfare State The Conservatives, whatever misgivings or ideological distaste for the National Health Service there might have been in some places, did not radically alter the system, until Margaret Thatcher. Welfare State

15. Welfare State During the 1950s efforts were made to make the system work. New hospitals had to be built and so on. Full--or practically full--employment helped ... In the 1960s, however, sociologists claimed that poverty had not been eradicated. Various reforms addressed this persistent problem. Welfare State

16. Welfare State Under Margaret Thatcher determined efforts were made to combat "scrounging" and encourage "responsibility". Many benefits were cut. More visible homeless. More recently, the introduction under Tony Blair's Labour government of a minimum wage has responded to a long-standing demand by the trade unions and others, though they said it was set too low. Welfare State

17. Welfare State NHS Housing Welfare State

18. Welfare State - NHS NHS Under the Thatcher governments a new philosophy was introduced: contracting-out of services (cleaning, catering, ...) and internal market GPs given funds to buy services for their patients Welfare State

19. Welfare State - NHS www.nhs.uk Welfare State

20. Welfare State - NHS www.nhs.uk Primary Care This is the care provided by people you normally see when you first have a health problem. It might be a visit to a doctor or dentist, an optician for an eye test, or just a trip to a pharmacist to buy cough mixture. NHS Walk-in Centres, and the phone line NHS Direct, are also part of primary care. All the people offering primary care are now managed by new local health organisations called Primary Care Trusts (PCTs). Welfare State

21. Welfare State - NHS www.nhs.uk Primary Care Trusts Primary Care Trusts (PCTs) are local health organisations responsible for managing health services in your local area. They work with local authorities and other agencies that provide health and social care locally to make sure the community's needs are being met. PCTs are now at the centre of the NHS and will get 75% of the NHS budget. As they are local organisations, they are in the best position to understand the needs of their community, so they can make sure that the organisations providing health and social care services are working effectively. Welfare State

22. Welfare State - NHS www.nhs.uk Primary Care Trusts For example, PCTs must make sure there are enough services for people in their area and that they are accessible to patients. They must also make sure that all other health services are provided, including hospitals, dentists, opticians, mental health services, NHS Walk-In Centres, NHS Direct, patient transport (including accident and emergency), population screening, pharmacies and opticians. They are also responsible for getting health and social care systems working together to the benefit of patients. Welfare State

23. Welfare State - NHS www.nhs.uk Doctors / GPs GP = General Practitioner Doctors look after the health of people in their local community and deal with a whole range of health problems. They also give health education and advice on things like smoking and diet, run clinics, give vaccinations and carry out simple surgical operations. Doctors usually work with a team including nurses, health visitors and midwives, as well as a range of other health professionals such as physiotherapists and occupational therapists. If a Doctor cannot deal with your problem themselves, they’ll usually refer you to a hospital for tests, treatment or to see a consultant with specialised knowledge. Every UK citizen has a right to be registered with a local Doctor and visits to the surgery are free. Welfare State

24. Welfare State - NHS www.nhs.uk Secondary Care If a health problem cannot be sorted out through primary care, or there is an emergency, the next stop is hospital. If you need hospital treatment, a GP will normally arrange it for you. NHS hospitals provide acute and specialist services, treating conditions which normally cannot be dealt with by primary care specialists. Primary Care Trusts are responsible for planning secondary care. They look at the health needs of the local community and develop plans to improve health and set priorities locally. They then decide which secondary care services to commission to meet people’s needs. Therefore they work closely with the providers of the secondary care services that they commission to agree about delivering those services. Welfare State

25. Welfare State - NHS www.nhs.uk NHS Trusts Hospitals are managed by NHS Trusts (also known as Acute Trusts), which make sure that hospitals provide high quality health care, and that they spend their money efficiently. They also decide on a strategy for how the hospital will develop, so that services improve. Trusts employ most of the NHS workforce, including nurses, doctors, dentists, pharmacists, midwives and health visitors as well as people doing jobs related to medicine - physiotherapists, radiographers, podiatrists, speech and language therapists, counsellors, occupational therapists and psychologists. There are many other non-medical staff including receptionists, porters, cleaners, IT specialists, managers, engineers, caterers and domestic and security staff. Welfare State

26. Welfare State - NHS www.nhs.uk NHS Trusts Some Trusts are regional or national centres for more specialised care. Others are attached to universities and help to train health professionals. Trusts can also provide services in the community, for example through health centres, clinics or in people’s homes. Except in the case of emergencies, hospital treatment is arranged through your GP. This is called a referral. Appointments and treatment at NHS hospitals are free. Welfare State

27. Welfare State - NHS www.nhs.uk Foundation Trusts Foundation Trusts are a new type of NHS hospital run by local managers, staff and members of the public which are tailored to the needs of the local population. Foundation Trusts have been given much more financial and operational freedom than other NHS Trusts and have come to represent the Government's commitment to de-centralising the control of public services. These Trusts remain within the NHS and its performance inspection system. The first 31 NHS Foundation Trusts have been authorised by the Independent Regulator and were established on 1 April and 1 July 2004, and 1 April 2005 Welfare State

28. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 Internal market The NHS experienced the most significant cultural shift since its inception with the introduction of the so-called internal market, outlined in the 1989 White Paper, Working for Patients, and which passed into law as the NHS and Community Care Act 1990. The internal market was the Conservative Government's attempt to address problems, such as growing waiting lists, which had arisen in the 1980s as a result of NHS resources being constrained while demand rose inexorably. Welfare State

29. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market, 'purchasers' (health authorities and some family doctors) were given budgets to buy health care from 'providers' (acute hospitals, organisations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services). To become a 'provider' in the internal market, health organisations became NHS trusts, independent organisations with their own managements, competing with each other. Welfare State

30. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 NHS trusts The first wave of 57 NHS Trusts came into being in 1991. By 1995, all health care was provided by NHS trusts. Over the same period, many family doctors were also given their own budgets with which to buy health care from NHS trusts in a scheme called GP fund holding. Not all GPs joined this scheme and their budgets were still controlled by health authorities ... Welfare State

31. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 GP fund holders Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holders. This led to accusations of the NHS operating a two tier system, contrary to the founding principles of the NHS of fair and equal access for all to health care. Welfare State

32. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 The New NHS: Modern, Dependable Observers credit the internal market with improving cost consciousness in the NHS, but at a price: that the competition it encouraged between 'providers' saw unnecessary duplication of services. The election of a new Government in May 1997 brought a new approach to the NHS. Pledging itself to abolition of the internal market, the new Government set out an approach which aimed to build on what had worked previously, but discarding what had failed. Welfare State

33. Welfare State - NHS www.nhs.uk NHS History 1988 - 1997 A new white paper issued by the Department of Health, "The New NHS. Modern. Dependable.", put forward a "third way" of running the service - based on partnership and driven by performance. The paper set out an approach which promised to "go with the grain" of efforts by NHS staff to overcome obstacles within the internal market, building on the moves which had already taken place in the NHS to move away from outright competition to a more collaborative approach. Welfare State

34. Welfare State - NHS www.nhs.uk NHS History 1998 to the present Since 1998 there has been a huge series of initiatives, financial and organisational changes, and alterations in policy. [ ... ] The NHS Plan - which was published in July 2000 - is a radical action plan for the next 10 years setting out measures to put patients and people at the heart of the health service and promising a 6.3 per cent increase in funding over five years to 2004. The NHS Plan promises: * More power and information for patients * More hospitals and beds * More doctors and nurses * Much shorter waiting times for hospital and doctor appointments. * Cleaner wards, better food and facilities in hospitals * Improved care for older people * Tougher standards for NHS organisations and better rewards for the best Welfare State

35. Welfare State - NHS www.nhs.uk NHS History 1998 to the present [ ... ] Shifting the Balance of Power Shifting the Balance of Power was launched in April 2001. It launched the NHS Modernisation Agency as the lead organisation in reforming the way the NHS works. The aim was to design a service that puts both patients and staff at the heart of the NHS... Shifting the Balance gave greater authority and decision making power to patients and frontline staff. The main feature of the change has been to give locally based primary care trusts the role of running the NHS and improving health in their areas. Welfare State

36. Welfare State - NHS www.nhs.uk NHS History 1998 to the present Creation of 28 Strategic Health Authorities Created in April 2002, covering an average population of 1.5 million, the main functions of the new Health Authorities include supporting Primary Care Trusts and NHS Trusts in delivering the NHS Plan in their area and building capacity and supporting performance improvement across all their local health agencies. In October 2002 the 28 Health Authorities received their 'Strategic Health Authority' status. All local NHS organisations became part of a single structure and held to account through their respective Strategic Health Authority. Welfare State

37. Welfare State - NHS NHS Prescription charges Charge per prescribed item from 1 April 2007 £6.85 (= approx 10 euros) For items dispensed in combination (duo) packs, there is a prescription charge for each different drug in the pack. Prescription prepayment certificates (PPC) as from 1 April 2007: * 4 months £35.85 * 12 months £98.70 http://www.dh.gov.uk/ Welfare State

38. Welfare State - NHS Help with NHS charges Entitlement to help with health costs (NHS prescription and dental charges, optical and hospital travel costs) is based on the principle that those who can afford to contribute should do so, while those who are likely to have difficulty in paying should be protected. Who can get help People can get help on age or medical grounds or by being in receipt of one of the exempting benefits or tax credits. People who have to pay NHS charges may be able to get help under the NHS Low Income Scheme. No help is available if a person has capital in excess of the limit: £8,000 (£12,000 if you and / or your partner are aged 60 or more or £20,000 for people who live permanently in a residential care home or nursing home). [not including value of patient's home] Welfare State http://www.dh.gov.uk/

39. Welfare State - NHS Help with NHS charges Help can be given for paying health costs for: * NHS prescriptions * NHS dental treatment * NHS wigs and fabric supports * Sight tests, glasses and contact lenses * Travel for NHS treatment under the care of a consultant You are already entitled to full help with health costs if you or your partner are getting: * Income Support * Pension Credit Guarantee Credit * Income-based Jobseeker’s Allowance Welfare State http://www.dh.gov.uk/

40. Welfare State - NHS Problems and criticisms The NHS has been criticised over the last 10 years or so because of waiting lists. Patients who had non life-threatening diseases might have to wait a long time for treatment, especially surgery. There have also been criticisms that the culture of indicators, results and so on has at least on occasions given the impression that the system was geared to meeting the targets and not necessarily giving the patients the best treatment possible. Welfare State http://www.dh.gov.uk/

41. Welfare State - NHS Problems and criticisms It would be wrong however to assume that the NHS has become a decrepit and ineffective monster. Medical care is of a very high standard and the system has become increasingly responsive to people's needs. It is cost-effective in comparison with other high-performance medical systems such as those in France and the USA. This may mean that it will be better equipped to deal with possible turbulent times for public health care in the future. http://www.frimleypark.nhs.uk/news/blair Welfare State http://www.dh.gov.uk/