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'The essence of a satisfactory health service is that the rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.' To what extent has Bevan's vision for the British national health service been realised?

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'The essence of a satisfactory health service is that the rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.' To what extent has Bevan's vision for the British national health service been realised? "Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you'll die sooner because you're badly off." (Frank Dobson/DoH, 1997 cited in Shaw et al, 1999) "Geographical inequalities have continued to grow... the worse off tenth of the population are 2.08 times more likely to die before age 65 than the best off tenth." (Shaw et al., 2001) A long history of analysis of health inequalities has continually stressed the role of socio-economic circumstances and location as causal factors (DOH, 2001). The sense of social injustice stirred by the link between poverty and ill health was a strong factor in the establishment of the NHS in 1948. In the same year, the UN Declaration of Human Rights enshrined access to basic standards of living to support both health and healthcare in international law (Pinch, 1997). Inequalities in health have remained a politically sensitive topic, to the extent that the Thatcher and Major Conservative governments of the 1980s and early 1990s rephrased the phrase 'inequality' with 'variation' when reluctantly discussing the issue (Benzeval, 1997). The election of Blairite New Labour in 1997 has returned the issue of health inequalities to the political limelight. Integral to Bevan's vision of the NHS was the concept of equity of service provision irrespective of income. An equitable health service may be defined as 'one that offers equality of access to health care to individuals in need', although the notions of 'need' and 'access' are themselves problematic (Dixon and Le Grand, 2003). For example, equality of access does not necessarily translate into equality of utilization as this may be mediated by cultural and socio-economic factors (ibid., 2003). ...read more.


According to Cooke and Hunter (1998), the implications of middle class opt-out are that 'a service for the poor becomes a poor service'. If an increasing number of the middle classes opt for private healthcare then they will be less willing to pay taxes to support an NHS they do not utilize which threatens the sustainability of the system (Cooke & Hunter, 1998). There is also a geographical element to the privatisation of healthcare, which has seen the largest growth in London and the South East. In regions of high levels of private healthcare provision, resource pressure is removed from the NHS facilitating a relatively higher standard of public healthcare services and thus reinforcing the health gap (Mohan, 1995). Therefore, in many ways the utilisation of private healthcare facilities contradicts Bevan's vision of equity in national healthcare provision. New Labour has been keen to espouse its commitment to equity in the NHS in several keynote speeches and policy documents (DOH website, 2004). In 2003, the government presented the Health and Social Care Bill which introduced the idea of NHS foundation hospitals which allows special status hospitals greater freedom over their budget, the ability to make independent decisions on investment and the type of services they would provide (Mohan, 2003). Foundation hospital reforms are archetypal policies of New Labour's 'third way' rhetoric which seeks to provide a mixed economy of public private partnerships, utilizing theories of market efficiency and private finance to enhance public services, in particular by increasing choice and diversity of service provision. Whilst the reforms have been presented as sensible and modest, it has been suggested that foundation hospitals threaten the equity of provision at the heart of the NHS (Pollock & Price, 2003). The TGWU has described the Bill as representing the 'backdoor privatization of the NHS... leading to a less equitable, two-tier health service' (TGWU, 2002). The Bill saw the governance of foundation hospitals transferred from the Secretary of State to independent corporations operating at a local level, which has serious implications for democracy and accountability (Pollock & Price, 2003). ...read more.


Black and ethnic minority schizophrenia patients also tend to receive higher doses of medication than white doses of patients with similar problems (BBC News, February 12th 2004). Discrimination in terms of inequitable access and standards of treatment has also been exposed on the grounds of age (for example, age-based rationing and the upper age limits for certain treatments) and sexuality (Age Concern, 2000; Scottish Executive, 2003). Many structural inequalities in NHS healthcare provision are reflected within the organisation itself, for example the 'snow-capped' nursing employment hierarchy where ethnic minorities tend to be at the bottom of the pyramid (Commission for Racial Equality, 2003). Disadvantages in the access and utilisation of the NHS may derive from a number of sources, including distance and transport, employment and personal commitments, voice and health beliefs (Dixon & Le Grand, 2003). It is therefore important to consider aspects of inequality in NHS healthcare beyond the question of income or class. In conclusion, Bevan's vision of equity in healthcare provision is far from being fulfilled. Over the past twenty years we have actually witnessed a step back in the achievement of this aim, which has been instigated by policies of rationalisation and privatisation. Cultural factors and wider social inequalities have served to aggravate these inequities. The reforms of the NHS since 1979 have been fuelled by political ideology, these decisions have not been independent decisions about organisational change and efficiency (Mohan, 1995). However, there is considerable evidence that it is inequalities income and not healthcare provision that accounts for the majority of inequality in health. Even if Bevan's vision of an equitable healthcare service was to be realised, this would be far from sufficient to prevent ill health on the grounds of poverty. A mild redistribution of wealth, an increase to benefit payments and improved security for lower paid workers are just a few examples of the wider economic interventions that would be required to tackle the greater problem of inequality in health. ...read more.

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