In the 1940s new legislation aimed to remove Beveridge’s five ‘giant evils’ of Want, Disease, Idleness, Ignorance and Squalor (NICE 2010). This was due to a shift in political ideology from the individualistic to the collective because the Labour government at this time believed in ‘democratic socialism’ partly as a result of societal change due to the Second World War. Another key example of this shift was the NHS which was established by Aneurin Bevan in 1948. The NHS had three key principles of the service being free at the point of delivery, being comprehensive in covering all individuals in Britain and that access would be based on need (NHS 2009).
In 1951 Labour pioneered the dental and eye service charge and prescription charges were only just avoided. However the Conservatives increased dental and eye charges and also introduced the prescription charge in 1952 which had two increases in 1956 and in 1961 which was the biggest policy change in the financing of the NHS (Webster, 1998:39). This shifted the political ideology away from collectivism because prescription charges meant that health care was no longer free for all.
Thatcherism was another shift away from collectivism as the government needed to meet the challenge of saving money due to a global recession and the NHS’s budget was a major use of resources. According to Taylor-Gooby (1988:2),
In the early and mid-1980s existing social divisions deepened: provision aimed specifically at poor minorities was tightly constrained, whereas services used by the mass of the population were little affected by spending cut-backs.
This was linked to the new policy where managers of NHS Trusts were given limited budgets and had to ensure that they remained within them which meant that some services had to be cut in order to ensure that they could balance the books at the end of the financial year (Walsh et al., 2000). This was a clear of example of health and social care managers needing to interpret government legislation and policies in order to ensure that they could meet targets needed to gain funding for the next financial year. This was carried out through the use of internal markets which were created by Thatcher’s government in order to streamline the NHS’s use of services and ensure that prices were competitive.
The next challenge to the NHS was New Labour’s election in 1997. According to Driver and Martell (1998) this led to a post-Thatcherite shift in political and social ideology where collectivism and the Welfare State began to be rebuilt. Their approach was to offer a diverse range of services, because of the wide diversity in individuals living in modern Britain. Who now had a longer life expectancy and to promote freedom of choice, with an emphasis placed on meeting the needs of their service users which was similar to the original NHS mandate (Driver and Martell, 1998). For example, in 2002, Primary Care Trusts (PCTs) were created to improve administration and delivery of healthcare services at the local level (NHS Choices, 2008). According to NHS Choices (2008), PCTs control over eighty percent of the budget and contract out services but that because they are local they can best understand the needs of their community.
PCTs moved away from Thatcherite management which had led to too many priorities being set, challenging the NHS’s ability to provide a healthcare service (West, 1997). PCTS were created with a “single management structure”, which meant that budgets and equipment was shared to provide an integrated service without wasting money, for the reason being that management was no longer spread among multiple people (Clouston, 2005:9).
Social policy and political ideology is once again challenging the NHS from 2010, as another global recession has led to the need to cut public services. This also shows a shift back towards the individualistic ideology of Thatcher. The White Paper Liberating the NHS (2011:3) aims to “putting patients at the heart of the NHS, focusing on improving outcomes” and “empowering local organisations and professionals”. This will be done by giving managerial power to GPs and those who are in direct contact with patients on a local level, which is similar to Blair’s plans although there will be a Central Commissioning Board in charge of ensuring financial targets are met.
However, health inequalities revealed in the Black Report (1980), the Acheson Report (1998) and the Marmot Report (2010) show that the NHS is still being challenged by Beveridge’s giants today.
Scenario 4: Health Trainers.
Choosing Health (2004) was put in place to help tackle health inequalities and to improve health by providing a new service that could help individuals to achieve a healthier lifestyle. The latest Department of Health (DoH) White Paper, Our Health, Our Care, Our Say (2006) mentioned the health trainers in the latest NHS ‘Life Checks’ and that the service’s ethos was to provide ‘support from next door’ (DoH, 2006:236). This new service brought in individuals who had experience in health inequalities and were from the local community (DoH, 2006). However Marmot (2009) states that inequalities exist because of “social inequalities in society, not simply because of inequalities in healthcare”, and that the solutions to those inequalities should reflect their causes and covers the “social, economic, cultural and political” (DoH, 2009:2).
A General Practitioner (GP) can encourage individuals that would seem unlikely to take part in any other health support schemes, to engage in this service as health trainers support individuals in Healthy Eating and Physical Activity, Diet & Weight Loss, Drugs & Alcohol, Sexual Health, Smoking Cessation, Smoking during pregnancy, Mental Health, Depression and Anxiety, Cancer Screening and Health Checks (DoH, 2004). Health trainers aim to inspire individuals in the community to change their lives which in return would help the individuals to have higher self-esteem, help them to become fitter and fulfil the primary objective- to lower costs for the NHS by reducing their burden on services due to an unhealthy lifestyle. The Yorkshire and the Humber Primary Care Trust (YHPCT) (2009) suggested that clients that used this service, 99% changed their lifestyle and improved their health by effectively helping them to control their existing conditions. This was mainly because they felt that the health trainers were local individuals, and could communicate with the community on their level, by empowering clients to think of solutions and helping them to maintain their choices (YHPCT, 2009). However in some cases individuals would be signposted to other organisations to help them with their lifestyle choices like Slimming World, where they would receive free vouchers every week, explaining how to access services where they would get extra help. This is just one of many ideas, which would also help with the equal allocation of health care equity. However the NHS geographical plan for health equity resource allocation is being denied with a wide range of variables in socio-demographic and socio-economic health care utilisation known as the postcode lottery (DoH, 2005b).
Policies need to evolve each year for the health trainers otherwise this could have an impact on the programmes. Health trainers should also be put into place in all health centres at a national level, which would support all individuals with inequality in their communities. According to the DoH (2011), their vision is for the financial strain on the NHS to be significantly reduced by the distribution of health promotion funds. In 2005 there were twelve sites for health trainers with each allocated ?200,000 to empower clients to transform their health and the DoH suggested there will be funding nationally until 2011 (NHS 2009). This is a significant shift in direction of public health policy from treating ill-health towards prevention by reducing inequalities as focused on by The Black Report (1980), the Acheson Report (1998), the Darzi Review (2008) and the Marmot Report (2010).
Prime Minister Tony Blair stated that individuals who want to improve their lifestyle have to make the decision themselves and that the government “cannot and should not pretend it can make the population healthy” but instead offer them the support necessary for them to do so (DoH, 2004:207). The health trainers program was a key tool for this strategy, although it took five years to put into practice and is still not present in all areas. As a result, Tony Blair said small changes can make a big difference to people’s lives this service is not yet available as “support from next door” to all individuals (DoH, 2004).
Scenario 5: Sure Start.
The Government has introduced detailed policies to tackle social determinants of health inequalities; which included the ten-year health inequalities targets and community-based initiatives including Health Action Zones, Sure Start and Healthy Towns. Health Action Zones (HAZs) were the New Labour government’s first important policy, using a multi-agency group to try to diminish health inequalities.
Acheson stressed how important the quality of life is in a child’s early years. (Acheson et al 1998). The New Labour government suggested that they want to radically reduce child poverty by 2010 and eliminate it by 2020. However these targets were missed in 2004-5, furthermore they are not on target for 2010-2011(Parliamentary Business, 2009). The New Labour Government poured three billion pounds into Sure Start when it was introduced in 1998, to try to provide help to disadvantaged families in the fundamental early years of a child’s life (Wilce, 2008). This would be done by trying to attain enhanced results for families and the community by increasing childcare, improving a child’s health and emotional growth and also supporting the child’s parents and encouraging them to strive towards employment (ET, 2007). However this vision for helping deprived families was an optimistic one as the government said that out of the 14 outcomes measured that related to health and child development, Sure Start only impacted on five; there was no positive impact taking place within language development, accidents, father’s involvement, maternal Body Mass Index, maternal smoking or children’s immunisations (Parliament UK, 2009).
In 2007 Education Today (ET) reported that Hull University conducted research about Sure Start which suggested that even though Sure Start was aimed at underprivileged areas, underprivileged and marginalised people were not gaining any benefits. The report also argued that Sure Start were generally taken up by middle-class families, and was not creating contact with minority groups such as travellers, vagrant workers and families of Bangladeshi origin and Sure Start was criticised for not employing any translators or staff from ethnic and minority communities (Bagley and Ackerley, 2006). There was also some apprehension over the deliverance and performance of a ‘Third Way’ multi-agency programme (ET, 2007).
It has been suggested that Sure Start has moved away from its first focal point on disadvantaged children and become a universal choice. Burkard (2010) argues that the government should fund disadvantaged children instead of the Sure Start centres, and that any nursery involvement that has money thrown into it, is more than unlikely to improve the life chances of children from deprived areas. The centres could be beneficial in other areas for mothers and children because children could have early gains in acquiring knowledge and social development, but they seem to almost immediately fade when children enter into full- time education (Burkard, 2010).
New Labour tried to implement strategies to prevent health inequalities through the early years of a child’s life with Sure Start, and national assessments have shown that Sure Start has been successful in some parts of eradicating health inequalities but only achieving five out of the fourteen assessments (Education Today, 2007). There needs to be a considerable amount of improvement when it comes to reaching minority groups and getting better health results for parents and their children. Furthermore, there are some fears that broadening this policy through children’s centres nationally would divert their main goal of helping reduce inequalities for the underprivileged families that need the support most.
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