'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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Part II – The Restructuring of the UK                          Louise Sherwin – Girton College

‘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). In this essay it will be argued that Bevan’s vision of an equitable health service has been eroded by the processes of rationalisation, privatisation and politically motivated distributions of health funding. However, it will be then be suggested that equity of healthcare provision is but one factor controlling inequalities in health, and that other factors outside the traditional remit of the NHS (such as income inequality) also need to be addressed in order to achieve Bevan’s ideal. Lastly, it will be suggested that other structural forces such as gender and ethnicity should also be considered in the achievement of Bevan’s goal of equity. The majority of this essay will refer to relative gaps in health care and health; however, it is important to note that absolute rates of mortality and morbidity rates have fallen dramatically over the last fifty years.

The British National Health Service (NHS) was established in 1948, under the leadership of the Labour Health Minister Aneurin Bevan. The NHS was founded upon the principle of a universal and complete healthcare service that was available to all citizens and free at the point of contact (Berridge, 1999). Inherent within this principle was the moral ethic of equity which suggested that the service should be based upon need rather than the ability to pay. The failure of market mechanisms to provide adequate healthcare for the poorest was highlighted during wartime evacuation programmes and this fuelled a strong political backing for the establishment of state controlled healthcare services. Over 3,500 private, voluntary and charitable hospitals were nationalised as part of the plan, with a considerable number of health workers (including GPs) becoming civil servants. The NHS was an integral part of the Keynesian demand economy and the post-war Labour governments’ efforts to construct a New Jerusalem against the context of the horror and destruction of WW2. Whilst many other countries adopted an insurance and local tax scheme to fund state healthcare services, the NHS funding model was derived entirely from centralised tax receipts. The concept of equity and its close synonyms of fairness and social justice has remained a key organising principle throughout the history of the NHS (Dixon & Le Grand, 2003).

        

        Three forms of poverty-related inequity will now be outlined, which suggest that Bevan’s vision for the health service has not been fully realised. The first relates to the de-institutionalisation of certain services (such as dentistry) from the NHS. The second form of inequity, and most highly publicised, is the geographical variation in healthcare that has arisen from differential resource allocation and infrastructure investment. The development of private healthcare and introduction of foundation hospitals will be used as case studies to illustrate this point. Lastly, it will also be suggested that cultural factors also influence health care equity, such as patient confidence and articulation.         

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        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 ...

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