Until the mid-1970s the consensus politics behind the establishment remained strong, facilitated by high employment levels and rising affluence (Lowe, 1994). However, by 1975 unemployment had exceeded one million and inflation stood at 27% (ibid., 1994). Welfare state expenditure and an associated ‘dependency culture’ was perceived as a prime suspect for the nations economic and social problems (ibid., 1994). Considerable rationalisation of the NHS was undertaken from 1979 through a number of policies. Progressive deinstitutionalisation has taken place in services such as long term care for the elderly and the mentally ill. Some services have been withdrawn from the NHS, such as dentistry and optometry, whilst charges have been introduced for others including prescriptions and medicals. The introduction of charging mechanisms, or withdrawal from the NHS altogether, for such basic services is a key impediment to the achievement of equity in healthcare. Under the current government low-income groups can receive refunds for some of these charges, however the administrative process to access them can be longwinded and complex. In their first term, New Labour also mooted the option of charging for GP consultations and missed appointments, both of which would serve to further inequalities in access to healthcare for those in poverty (BBC News, 1999).
A second stumbling block to the achievement of equity in the NHS has been the continual geographical differentials in both infrastructure and resource funding. In 1971, Hart neatly encapsulated this phenomenon as the ‘inverse care law’ which referred to the way in which poorer areas with greater health needs tended to be less well served by the NHS. To a certain extent geographical variations in healthcare provision are a legacy of the pre-war distribution of private, voluntary and charitable hospitals which were concentrated in the south east and have since provided a useful capital legacy for healthcare in these regions (Mohan, 1995). However, subsequent political decisions over NHS funding have exacerbated this problem (ibid., 1995). For example, the NHS internal market introduced by the Thatcher government of the 1980s saw the net transfer of funds from acute care in inner cities to provision in suburban locations and this move was strongly connected to electoral politics (ibid., 1995). The rejection of resource allocation mechanisms taking into account social factors and the differential opportunities for hospitals in different areas to raise funds through entrepreneurial activities has also served to heighten geographical inequalities in the provision of healthcare (ibid., 1995). Since coming to power, New Labour has introduced new formulae for the distribution of monies to Primary Health Care Trusts which takes ‘unmet need’ into account for the first time and may serve to reduce inequalities in this area of healthcare (DOH website, 2004). Privatisation and foundation hospitals represent two interlinked examples of how differences in physical infrastructure and resource allocation can create inequity in healthcare provision, and these developments will now be discussed in detail.
The ideology of the NHS has been further threatened and eroded by the development of private healthcare alternatives through both health insurance schemes and private payment for individual treatments (Pinch, 1997). Considerable growth of private sector healthcare was observed in the early 1980s, resulting from both active encouragement from the Conservative government (such as tax relief and the relaxation of rules on private practice for NHS consultants) and also indirectly, as waiting lists and service quality declined as a result of NHS funding cuts (Mohan, 1995). The internal market introduced by the conservatives also encouraged the use of independent services via fundholding GPs (ibid., 1995). This trend has continued under Labour with over 70,000 NHS patients treated in private facilities in a bid to reduce waiting lists (IHA website, 2004). The number of people covered by private healthcare insurance in 1971 was 2.1 million and by 1990 this had tripled, to 6.7 million. Since then, the number of people covered has stabilised and 11 per cent of the population were covered by private medical insurance in 1999 (NSO, 1999). However, the number of 'self-pay' cases - people with no medical insurance, paying for operations at private hospitals - rose by more than 25 per cent over 2001/2002 to more than 250,000 (IHA, 2002). The growth of private healthcare has both short and long term implications for the equity of healthcare service provision. Private healthcare offers those with more money or those in certain professional categories of employment, the ability to opt-out of the system thereby threatening the very nature of a public or merit good and the idea of equity in healthcare provision (Samuelson, 1954). 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). Increasing local governance could allow foundation hospitals to increasingly serve ‘the choices of the few, rather than the needs of many’ (Mohan, 2003). The Bill also has geographical implications, as the proceeds from the sale of NHS assets (such as property) would be reinvested at a local level rather than allocated centrally and according to need (Pollock & Price, 2003). It may be argued that geographical divisions in health will widen under this policy, as hospitals which benefit from favorable local and economic conditions (such as the availability of a large and willing body of volunteers, greater incidence of private healthcare which thereby reduces the pressure on the NHS and a greater labour market skill base) will comparatively be more able to release assets or improve efficiency and then reinvest the surplus locally rather than redistribute it (according to need) from a centralized purse. The longer-term impact of the policy remains to be seen, however in theory, foundation hospitals present a real challenge to the principle of equity within the NHS.
A third source of inequity within the NHS may result from cultural factors. Recent research by Dixon & Le Grand (2003) has suggested that causes of inequalities in the use of healthcare services go beyond questions of resource allocation alone. A number of case studies demonstrated that the middle classes appeared to get more out of the health service than lower socio-economic groups. For example, it was found that that affluent achievers in Yorkshire had 40% more heart bypasses and angioplasties than those in a group of ‘have-nots’, that hip replacements were 20% lower among socio-economic groups despite a 30% higher need, and that people aged 16-44 from lower socio-economic groups had 10% fewer consultations with their GP for preventative care than those in groups I and II (Dixon & Le Grand, 2003). Those in lower socio-economic groups experienced disadvantages in both accessing the health service and also utilizing the service to the same extent as the middle classes (ibid., 2003). For example, when ill the poor tend not to go to the doctor at all, or to present themselves at a later stage of illness (bid., 2003). Once in the system, they experience further difficulties which are manifested in lower rates of referral to secondary and tertiary care and lower rates of intervention relative to need (ibid., 2003). Many of the causes behind these wide variations are founded upon cultural variations, rather than inequalities in healthcare resources and physical infrastructure. Cultural factors include access to a network of contacts working within the NHS who can provide informal advice and encouragement as well as a better standard of education and greater confidence and articulation which facilitates diagnosis and access to treatment (ibid., 2003). These cultural factors may be seen as a further impediment to delivering Bevan’s vision in equitable healthcare provision.
Many nation-wide geographical analyses of morbidity and premature mortality have stressed the role of poverty-related factors in the determination of health inequalities, rather than the variation in healthcare provision itself. The Black Report, an independent inquiry into ill health published in 1980, became infamous an example of the political suppression of a contentious report. The Conservative government restricted circulation to 260 copies and published it on an August Bank Holiday (Berridge, 1999). During the 1980s and 1990s, the conservative governments of Thatcher and Major actively resisted acknowledgement of the links between poverty and ill health. Individual agency and morality routed through lifestyle choices (such as smoking and exercise) were championed as the root cause of health inequalities rather than any underlying structural constraints (Shaw et al., 1999). However a number of recent investigations into health inequality have emphasized the link between poor health and low income (Dorling, 1997; Higgs et al, 1998; Shaw et al, 1999). In an analysis of the differing socio-economic characteristics of the ten ‘worst’ and ‘best’ health constituencies in the UK (indicated using statistics on premature mortality), Shaw et al (1999) found that 70% of the health gap could be accounted for by income inequalities between the regions. The relationship between poverty and poor health was prevalent throughout the life cycle and influenced by factors such as child poverty, GCSE failure rates, social class, unemployment, income and car ownership (Shaw et al., 1999). The studies have also shown a widening health gap over the 1980s and 1990s, which is intimately related to increases in income inequality (Dorling, 1997; Shaw et. al, 1997). Conservative policies such as the abolition of the link between social security benefits and earnings, restraints on the value of child benefits, the abolition of on parent allowance and the substitution of means-tested benefits for social categories all served to increase inequalities in health over the past two decades (Shaw et al., 1999). In 95% of constituencies, demographic and socio-economic change accounts for virtually all of the change in mortality rates since the early 1980s (Mitchell et al., 2000). This suggests that there is the potential for wider economic polices to have considerable impact in reducing health inequalities. Mitchell et al. (2000) propose that this could be achieved through three key measures, a modest redistribution of wealth, the achievement of full employment and the eradication of child poverty. New Labour have introduced a number of policies which could help to achieve this aim, such as the Working Families Tax Credit, the New Deal and the re-linking of some security benefits to earnings. The government has also commissioned the development of a Health Poverty Index (HPI) which will facilitate the analysis and tracking of the impact of these policies (Dibben et al., 2004).
Whilst Bevan’s vision of equity in the NHS was largely driven by economic divisions in access to healthcare, subsequent social critiques have also raised gender and ethnicity as further important structuring constraints. State institutions can act as powerful devices for the reflection and refraction of wider social inequalities. The ‘domestication’ of institutional patients in the 1970s and 1980s under the banner of community care is one of the more widely cited examples of the gendered implications of NHS policy. The 1990 NHS and Community Care Act embodied three key elements of Thatcher and Major neo-liberal welfare policy, the increasing reliance upon both self-provision and voluntary associations, and the deinstitutionalization of large populations (Pinch, 1997). Large numbers of mental health patients were transferred out of residential care and into the community, however, the resultant savings were not re-invested in community infrastructure and the responsibility of care frequently fell upon women, “the result has been care ‘in’ the community but not ‘by’ the community”(ibid, 1997). The recent Blofeld Inquiry into the death of David Bennett, a black mental health patient, described racism as a ‘festering abscess’ and a ‘blot on the good name of the NHS’ (Guardian, February 7th 2004). Research by Rethink, the UK’s largest severe mental illness charity, has revealed that black and ethnic minority users are 40% more likely to be turned away when they ask for help than their white counterparts and that 88 per cent of black respondents had been forcibly restrained under a section of the Mental Health Act compared to 43 per cent of white respondents (Rethink, 2004). 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.
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