Welfare and Society (Health and Society).

Le-Grand (1982) found in his research that access to health care is biased in favour of the non-manual socio-economic groups in terms of access, treatment and quality of care; compared to class ? social group. This has contributed partly to some social groups experience poorer health than others. Inequalities in health care is influenced by several "supply" factors: the geographical distribution and availability of primary care staff, the range and quality of primary care facilities, levels of training, education and recruitment of primary care staff, cultural sensitivity, timing and organisation of services to the communities served, distance, and the availability of affordable and safe means of transport. "Demand" factors such as lay health beliefs, knowing what services are available locally and wider socioeconomic influences, such as financial insecurity, social mobility and lack of informal carer support will also affect patterns of utilisation and access to health care.

Higher rates of general practitioner (GP) consultation are associated with greater social and economic deprivation even after adjusting for need. However, the further away patients live from their GP, the less frequently they tend to consult. This is evident in rural areas, although the differences are not as great for serious health problems as for less severe ones.

According to "inverse prevention law", communities most at risk of ill health tend to experience the least satisfactory access to the full range of preventive services, (Tudor-Hart 1971). Prevention services include cancer screening programmes, health promotion and immunisation. While differences are most noticeable amongst socioeconomic groups it is likely that, for example amongst Bangladeshi women, additional inequalities in access are experienced. Lack of access to women practitioners can be a deterrent to Asian women taking up an invitation for cervical cancer screening4. Local studies have shown that access to female practitioners is poorest in areas with high concentrations of Asian residents and that practices with a female doctor or nurse are more likely to reach the cervical cytology targets set out in the GP contract. Sub-regional and small area analyses illustrate this inequity for areas such as Liverpool and Birmingham where, using nine indicators of primary care services, the most deprived areas tended to be the least well served. Within London, health promotion claims by GPs are highest in the least deprived and lowest in the most deprived areas.

Figure 17 shows the statistics of GP health promotion claims, by Jarman (UPA) score of health authority, London Boroughs, October 1995 (see separate attached statistics sheet).

Although the general standards of health have improved dramatically since Chadwick reported the massive inequalities of early nineteenth century London the prevalence of chronic sickness still varies according to social class as Table 1 shows, which to point up the contrast, compares professional with unskilled, male and female, young and old.

Socio economic group

Male

0-15yrs

Male

65 and over

Female

0-15yrs

Female

65 and over

Professional

Unskilled

6

28

57

68

1

8

53

65

Source: Social Trends Office of Population Census and Survys, 1994, page 86

Table 1 : chronic sickness rates by social class, UK 1994 (%)

The figures in the table indicate the continued inequalities in both morbidity and mortality across social classes. There are clear differences in the incidence of ill health by social class. Figures from the UK show that people in lower social classes, including children, are more likely to suffer from infective and parasitic diseases, pneumonia, poisonings or violence. Adults in lower social classes are more likely, in addition, to suffer from cancer, heart disease and respiratory disease. ore likely, in addition, to suffer from cancer, heart disease and respiratory disease

Such differences were explored in detail in the UK by Townsend and Davidson (1982) who argue that the most important factors affecting health were income, occupation, education, housing and lifestyle. They examine four types of explanation that have been used to account for the statistical data.

It seems unlikely that having divided the entire population into about six large social classes, a single explanation would account for all the health differences between them. Whitehead et al (1995) explained four main explanations to help understand the reasons for the persistence of inequalities in health, but only two will be looked into in this assignment (the artefact and the cultural/behavioural explanation):

* Artefact-the association between social class and health is as artefact of the way these concepts are measured.

* Social selection-health determines social class through a process of health related social mobility.

* Culture-social class determines health through social class differences in health-damaging or health promoting behaviours.

* Material/structural-social class determines health through social class differences in the material circumstances of life.

The artefact explanation:

This suggests there is no 'real' problem to explain: social class health inequalities do not exist in reality: they are simply a product of the methods researchers have used to measure social class and health inequality.

According to (Black Report 1980), the measure used do make a difference point out that class gradients are steeper if 'years of potential life lost' rather then 'standardised mortality rates' are compared. Also researchers who focus on the health differences between class I and class V could be accused of selecting two relatively small classes at the extremes of the social scale, and therefore exaggerating class differences.

However there is no convincing support for the view that the artefact explanation would require us to ignore the fact that different measures of social inequality for example occupation, housing tenure) show a fairly consistent social class gradient: the lower the social class, the more health deteriorates and life expectancy decreases.

Accepting the artefact explanation means that no social policies would be needed to deal with this (non-existent) problem.

Cultural and behavioural factors:

Cultural and behavioural explanations for inequalities in health emphasise the importance of differences in social circumstances and in the ways in which individuals in different social groups choose to lead their lives: in other words, in the behaviour and voluntary lifestyles they adopt. Thus 'inequalities in health evolve because lower social groups have adopted more dangerous an health damaging behaviour than the higher social groups, and may have less interest in protecting their health for the future' (Whitehead, 1988).

The cultural/.behavioural explanation focuses on people's individual responsibility for their own health and the degree to which they jeopardise or enhance their chances of good health through the choices that they make about their lives. Evidence from the studies such as the "General Household Survey" (1993a) and the "Health Survey of England (OPCS) shows that people in lower social groups tend to lead more unhealthy lives because they smoke more, eat less healthy food and exercise les. In 1990, for example, 16% of professional men and women smoked compared with 48% of men and 36% of women in social class V (Central Statistical Office, 1993a). However, cultural and behavioural factors are still insufficient as a full explanation of health inequalities. As Marmot et al (1984) have shown , when a comparison is made between individuals from socio0economic groups I and V whose smoking, eating, drinking and exercise habits are broadly similar, health inequalities still persist.

Therefore when looking at inequalities in health we must recognise that materialistic and cultural differences are probably the most important in explaining health inequalities in the UK. It appears that poverty and its associated culture are the main causes of poor health and the health choices of UK citizens.

Differing behaviour and beliefs in people in different social classes may be responsible for health differences. People in lower social classes are known to have less healthy lifestyles and lower expectations of their health than those in higher classes: they inhale more smoke of smouldering dried tobacco leaves, take less exercise, drink more alcohol and have worse diets (Blaxter 1990, pl45).

Exercise

Activities by social economic group in 1973,83 and 96 shows two of the most popular actives like walking and swimming. In both professional groups had the highest participant and the unskilled manual groups the lowest. However there was an increase in the participation from 1977-1986 for all groups but the social gradient remains. When considering strenuous activity in manual occupation in Scotland for both men and women (Cromdie et al 1990). In Wales a similar increase and at work a decreasing social class was seen for men, but no gradient was evident for women (Nutbeam et al 1987). It is difficult to say from these results whether any social class has a healthier pattern of physical activity than others, especially as vigorous activity are so low in all social classes that those who take adequate exercise are in a minority in each group. Exercise may be linked to health in several ways including a possible protective against coronary heart disease.(Morris 1981)argue that it is clearly possibility due to cultural norms and voluntary behaviour rather than to material barriers to take up such as limited access. Evident suggests that differences in life style could account for some of class differential in health.

Smoking

Smoking is the single greatest cause of preventable illness and early death in England. Cancer and heart disease and stroke are two of the top three causes of death in East Sussex and Brighton & Hove. Over 120,000 people in the UK die each year from these diseases as a result of smoking. This represents 300 deaths per day or 13 deaths per hour. Although nationally fewer people overall started smoking since 1988, there has been an increase in the numbers of young people starting to smoke in recent years.

An interpretive study of the smoking habits of working class mothers showed that for many smoking was an essential element of their coping strategies. Graham's in-depth interviewing revealed that smoking provided essential 'time out' for the mothers and was crucial to their maintaining caring roles and thus the welfare of their families.([Graham 1987)

Food and Nutrition

For example, more obesity in classes 1V and V as shown in item G data below:

Obesity, measured by the 'body-mass index', correlates with social class. Over 25% of women in social classes 1V and V are obese, compared with under 15% of those in classes 1 and 11. Fewer men than women in each social class are over-weight, but there is a similar inter-class pattern. Part of the explanation lies in the inferior diet of working class people: the middle classes eat far more fruit and vegetables and far less sugar.

Item G

Men Women

Class V 20% 31%

Classes 1 and 11 12% 15%

[Source: Social Trends 32, ONS, 2002]

[Source: Monitoring Poverty and Social Exclusion, 1999, New Policy Institute]

The X factors

Michael Marmot, professor of epidemiology and public health at University College London, suggests two factors which might explain why working class people, with behaviours similar to those of middle class counterparts, have worse health chances:

Stress, which is more commonly found amongst those lower down(( the

social scale who lack autonomy and, as a result, do not feel in control

of their lives.

Feelings of inadequacy caused by low status. Analysis of(( international

data shows that if others become richer, and your income remains the

same, you are more likely to become ill.

Further evidence on the elusive X factor comes from Dr Connor O'Shea of Duke Medical Centre in North Carolina, leader of a research team which spent two years looking at 10,000 heart-attack patients throughout the world. The researchers found that those who leave school at 16 are five times more likely to die after suffering a heart attack than university graduates. Dr O'Shea says "It could be an unlimited number of factors, including stress, poor understanding of the disease process and not making the necessary lifestyle changes to promote a better outcome."

Conclusion: Over the last decade, the gap in good health between rich and poor has become wider and inequalities in health are large and increasing. Although huge advances have been made in the medical and surgical treatment of illness over many years, our society is still divided in terms of good health.

Differences in people's health used to be linked to their behaviour and lifestyle. Although individual behaviour does influence health, eg; 80-90% of all cases of lung cancer are caused by cigarette smoking, only about a quarter of the health inequalities between social groups can be explained by differences in smoking, drinking, diet and exercise. Put another way, three-quarters of these differences can not be addressed by changing people's behaviour alone. According to experts at Bristol University's Townsend Centre for International Poverty Research (CIPR), the only way to effect a significant improvement in the nation's health is by pursuing "policies which actively address the reduction of poverty and of inequality through redistribution [of income and wealth]." [ 1999

A major obstacle to reducing health inequalities is that successive governments have been preoccupied with health services rather than health. And whilst there is a relationship between poor care provision and ill health, it is far weaker than that between low economic status and ill health.

Excess deaths attributed to government policy :

Government policies since the late 1970s, which induced high rates of unemployment, increased child poverty and promoted greater inequalities of income and wealth, led to the premature deaths of thousands of British people according to researchers at Leeds and Bristol Universities funded by the Joseph Rowntree Foundation (JRF). The researchers found good correlations in just about every parliamentary constituency between the mortality rate and the level of relative deprivation.

Statistical analysis suggests that a return to the (lesser) income and wealth differentials of 1983 would prevent about 7,500 deaths a year among people aged under 65. Another 2,500 lives a year would be saved by eliminating long-term unemployment; eradicating child poverty would reduce the annual death toll among children under 15 by 1,500.

The study identified 45 constituencies where 25 or more lives could be saved each year by reducing relative deprivation and long-term unemployment. In Birmingham, Ladywood, one of Britain's most deprived constituencies, an average of 275 people aged under 65 died each year in the early 1990s, compared with a national average (adjusted for population size) of 182. 54 of the 'excess' deaths can be explained by factors other than inequality, child poverty and unemployment. This leaves 39 lives a year lost in just one constituency because of deliberate policy changes implemented by successive governments.

[Source: Inequalities in Life and Death: What if Britain were more equal?, 2000, Joseph Rowntree Foundation]

Health and illness as socially defined: According to Whitehead et al (1995) there are different meanings attached to health, but the two main approaches are medical and social models of health. Medically, disease is seen as mainly caused by biological factors, and personal factors such as smoking and diet. The model believe that ill-health arise from the moral failings of the individual (too much smoking and and not getting enough exercise) or sudden attack of disease. But the social model of health, emphasis on the social causes of ill-health and how society influnces health (social conditions). Contrast to medical or scientific facts, It is possible both to have a disease and not feel ill, and to feel ill and not have any disease, depending on doctors classifying someone ill or if people see themselves as ill or not. But according to WHO (1984) health is a state of complete physical, mental, and social well being, and not merely the absence of disease or deficiency while IIIness is the subjective feeling of being unwell or ill-health.

Health and illness can be seen as socially defined, because definitions of health and illness are very complex; in that there are cultural differences in how societies classify what are health and illness, the causes and the treatment. However because disease occurs in patterns it is thought that the conditions that determine health chances are social conditions. The way we think about health and illness is socially constructed as we are used to accepting the views of the medical profession. In modern medicine our bodies are seen as machines and doctors as mechanics, however studies by sociologists show that there is a range of environmental, political and behavioural factors that contribute to the construction of health and illness. In societies what appears to be abnormal or unacceptable is often labelled as disease, conflicts arise because what accounts for illness differs from place to place and from time to time. Numerous studies also show that a person's social class strongly affects health and longevity, and that poverty and social class are the most important factors determining health. The lower ones social rank the more prone one is to early death. Beliefs about gender also influence attitudes to health and illness, as what is natural becomes medicals when women's natural reproductive cycles and childbirth are often treated as disease. (Whitehead et al 1995)

There is substantial evidence that illness is socially constructed through the medical professions intervention in creation of iatragenic diseases ( ), in many cases the treatment causes more damage than the illness ever would. For example the thalidomide drug where the effects on the unborn children greatly outweighed the advantages to the pregnant women. People suffering from depression are often given tranquillisers this in turn can cause addiction. There is also much evidence to suggest that there are many unpleasant side effects to the contraceptive pill as it can cause cancer or thrombosis and intra-uterine devices (IUD) can cause all sorts of infections; however they continue to be used by the majority of women, as there is little choice of other methods of birth control.

Health and illness are socially constructed by the environment. Technological changes over time have brought improvements in sanitary systems ending the risks of major epidemics; however this industrialised engineering has also brought about high levels of dangerous chemicals with the result that the major killers in modern industrial societies are heart diseases and cancers. According to Pinker, "The idea that disease emanates from an individuals relationship with his environment was part of Greek medical orthodoxy and, as anthropologists (person who study scientific and development of human race) have discovered, is a quite common concept in other cultures" (Walsh et al 2000).

Medical matters are often socially constructed through the beliefs of the medical profession and their power to control the behaviour of society, this happens when alcoholism, smoking or obesity are seen as unacceptable and so are labelled as disease which society finds easier to accept. Treatments are then created to try to cure the behaviour of the individual. In the 19th century women who didn't conform to the stereotyped female role were often regarded as suffering from a disease. This is where the power of the medical profession can be clearly seen. (Moonie 1998)

Our ideas in society tend to construct gender differences in health problems, there appears to be some evidence that men take more risks than women such as dangerous sports and violent activities and hazardous occupations, also women tend to consult doctors more often but yet statistics suggest women have more ill health, but this could be because women in their socially produced gender roles are seen as more acceptable to show weakness and seek medical help. Women's lives are more often medicalised than men, in childbirth, reproduction and mental health women are more likely to be given prescriptions for anti-depressants or tranquillizers, men however are more likely to have alcohol related problems, a more socially acceptable response to stress than it is for women. Peter Sedgwick found that "About 10% of all GPs prescriptions and 20% of annual expenditure goes on tranquillisers, anti- depressants or hypnotic drugs, mainly for women".

A woman's role is often looking after everyone in the family and because she tends to carry an added burden of stress with an attitude of having to soldier on with her responsibilities she may be prone to physical and mental disorders. As victims of social and economic circumstances, women tend to suffer from what is known as "housewife syndrome". The isolation and constant decision making involved in housework are very stressful as is the responsibilities of looking after young children. In addition there are certain illness's that women suffer from because of their biological makeup, women live longer but they tend to suffer from degenerative disorders. (Graham1987).

"From a sociological point of view, there is no objective definition of illness; instead it is necessary to ask whose interest, and with what purpose in mind, illness is socially defined by different people" (Gomm 1998)

High levels of illness are seen as a threat to society thus the medical profession serves to ensure the satisfactory performance of social roles yet the major effect of the intervention of the medical profession actually increases the numbers of people diagnosed as sick. The large drug companies which are the most profitable in the world help shape the pattern of medicine, drugs are made to produce profit therefore there is a relationship between doctors and drug companies designed to maximise the sale of drugs. The elderly in society are also often diagnosed as sick because they are most vulnerable to illness; a large number of the elderly are in hospitals not because they are sick but because there is no one to look after them at home and also because health and welfare services fail to provide enough care in the community. (Browne 1993).

The social construction of health and illness is a complex interaction of gender, class, age and other social characteristics; still vast social divisions of health outcomes, social class divisions in mortality and morbidity are probably the result of material factors, what is defined as disease often occurs in patterns which are best understood sociologically. Evidence from medical historians concludes that medical intervention has been less important in promoting health than have other social and economic factors. The improvement in life expectancy over the years is because epidemic diseases were reduced with improved sanitary conditions. Looking at it in this perspective, modern medicine has been less important than changes in environments.. It would appear that there is something much bigger going on with the career interests of the doctors and the commercial interests of the drug companies. (MCkeon 1976)

The structure of national health services is based around the National Health Service (NHS) which was formed in 1948 by the National Health Service Act. The Act brought the health services, and in particular the hospitals, under the control of the Department of Health.

Before the Act, most of the hospitals had been controlled by charities or voluntary organisations. The idea behind the setting up of the NHS was to provide health care for all that did not involve charging patients directly.

The original goals of the NHS were to provide a comprehensive health service, to improve physical and mental health and to prevent, diagnose and treat illness.

together from a national to a local level relating to each other.

Source: http://.oheschools.org/ohech4pg2.html

The structure diagram of the main institutions of the NHS today

The diagram below shows the structure diagram of the main institutions of the

NHS today (April 2002) with an overview of how NHS organisations work

The organisation of the NHS changed dramatically in April 2002 with the removal of executive and regional layers, fewer health authorities and a pivotal role for the newly created primary care trusts.

The major impact of these changes is to put patients at the centre of NHS services by shifting the balance of power towards frontline staff, which are best placed to understand patients needs. In this way frontline staff, patients and local communities will have more say in how health services are developed. The systems in the rest of the UK are similar but differ in numerous details.

Secretary of State for Health: At the top is the Secretary of State for Health, the government minister in charge of the Department of Health, responsible for the NHS in England and answerable to Parliament.

The Department of Health and the NHS Executive: are responsible for the strategic planning of the health service as a whole (public and social care). The DOH is the government department responsible for delivering a fast, fair, convenient and high quality health and social care service to the people of England. The department is responsible for giving NHS organisations, such as hospital trusts and GPs, the information, guidance and support they need to deliver the government's policies and meet its standards of patient care. It supports government ministers in developing the standards and broad working practices of the NHS and local social services. It monitors standards and takes steps to deal with services that are poor or failing. It also works on ways to prevent disease and help people live longer, healthier and more independent lives.

Strategic Health Authority: does not directly provide health services, but manages the NHS locally by working closely with local primary care trusts (PCTs) and NHS Trusts. It is responsible for encouraging helpful networking across health, social care and other agencies, for ensuring high and consistent standards of treatment and care of patients and for achieving health improvements in the population as a whole.

Primary Care Trusts (PCTs): are now the cornerstone of the NHS and provide the vital links between the strategic health authority and GP practices and between the demand and supply of acute hospital services. Overall, they are responsible for the health of the people in their area, tackling health inequalities and bringing health and social care more closely together. They have much more flexibility, independence and control of funds . The role of the PCT is to steer and support the work of GPs and practice teams, provide a range of community health services, through local clinics and hospitals, and commission treatment for patients in acute hospitals.

NHS Trusts or secondary care: which is refer to as hospital trusts are found in most large towns and cities, and usually offer a general range of services to meet most people's needs. It is set up to deliver NHS healthcare-the trm relates to organizations providing primary, secondary and community care. Some trusts also act as regional or national centres of expertise for more specialised care. Trusts can also provide services in the community - for example through health centres, clinics or in people's homes. NHS trusts employ their own staff, and compete for the contracts to provide health care alongside private and voluntary sector providers. NHS trusts employ the majority of the NHS workforce including, doctors, dentists, pharmacists, midwives, health visitors and staff from the professions allied to occupational therapists and psychologists. Individual's hospitals, community health services or services such as ambulance service opt for trusts status. Trusts have responsibility for managing their own money. It is expected that this competition for money will increases the value for money of health care provided.

primary health care : this is the frontline of the NHS, introduced in the White Paper on the NHS (Department of Health 1997). They are most people's first lport of call when they have a health problem. Service providers include doctors, pharmacists and opticians, heath visitors and district nurse.

secondary health care: the more specialised treatment, second stage of treatment, if needed, after primary care; which we use less often and are usually provided by an hospital are called 'secondary care'. This includes not only hospitals but also ambulances and specialized health services for the mentally ill and the learning disabled. Secondary care services are provided by hundreds of NHS organisations called "Trusts". It usually involves a hospital visit as an outpatient or inpatient.

Services provided by Primary Health Care includes, provides a setting where health promotion at primary, secondary and tertiary levels takes place. such as GPs, dentists , as well as staff employed by them such as practice nurses. Together, these professionals make up primary health care teams who provide a range of health care services for everybody in the community

The main purpose for primary health care is to ensure that local community have access to the right care by the right provider when and where they need it.. PHC is an important setting for health promoting, focusing on treatment, providing an opportunity for building health gain into existing services. As a setting, PHC prides unique access, trust and credibility. Primary Health Care are part of NHS services provided in the community, serving as first point of contact when people have concern about some aspect of their health. The PHC services can be access directly or self referral. PHC is one of the strategies set to help bridge the health care gap between hospital and the community thereby reducing inequalities and improve community health. Primary health care provides a setting where health promotion at primary, secondary and tertiary levels takes place For example GP practises often involve a group of health care professionals include independent cotractors providing NHS care. Also may have other health care professionals working with them, such as district nurse, health visitors, dentists, opticians, pharmacists, sometimes social workers and a range of specialist therapy. NHS Direct and walk-in-centres are also part of primary care. Each PHC group, is an independent contractors will the NHS provides general medical services, which typically covers a population of about 100,000. Their function includes:

- deliver local health care and concentrate on improving health thereby reducing the number of cases sent to secondary care settings.

- specify minimum standards of care.

- meet specified targets for various preventative measures like vaccination, screening, well man and well woman clinics and possibly some minor surgical treatments.

- be available 26 hours each week over five days and accept 24-hour responsibility for patients

- Provide more services for the over-75s (including the offer of annual check ups and home visits) and a more regular assessment of the development of young children.

While primary care can meet around 90 per cent of the needs for health care, preventing illness as well as curing it; more intensive diagnosis and treatment is sometimes needed i9n secondary care.

General practioners (GPs): known as doctors usually is the first level of contact of individuals , the family, and the community, providing primary health care to NHS patients as close as possible to where people live and work. The vast majority of medical episodes are dealt with by GPs outside of hospitals. Under the NHS and Community Care Act 1990, larger GP practices may apply for budgets for their practices, to buy in a defined range of secondary services on behalf of their patients.

GPs work from small neighbourhood practices or surgeries, diagnoses your illness and if necessary either gives you a prescription. When they are not able to solve health problems or treat on-going conditions, they refer patients to specialist health care practioners for better diagonise and be treated in hospital either as a day patient or as an inpatient. These health care professionals are acting as your agent to overcome the information problems between professional and client thereby improves communication. GPs may work as part of a primary health care team including nurses, physiotherapists, chiropodists, and even social workers. But this means that the quantity and type of medical care produced is not normally influenced by your preference to pay.

Pharmacists, often called chemists, are experts on medicines. They usually work in high street shops or units in supermarkets. They make up prescriptions issued by your doctor and can also advise on treatments that can be bought over the counter. Some pharmacists not only dispense medicines but also advise residential homes on the safe keeping and correct administration of drugs. Some keep records of drugs supplied to certain patients on long-term medication. Pharmacists also provide leaflets and information on health care matters.

Opticians: are eye specialists. Opthalmic medical practitioners are specialist doctors, Opthalmic opticians or optometrists carry out eye tests and prescribe glasses, and dispensing options who supply and fit glasses to prescriptions provided to correct sight problems. A dispensing optician fits and sells glasses but does not test eyes.

Dental practitioners: work within the NHS determine the number of hours they are prepared to devote to the NHS and the range of services they are willing to provide. NHS contract with dental practitioners includes a requirement to explain the treatment plan to patients and its probable cost.

Community health services: district health authorities are responsible for assessing the health needs of their resident populations, and these are provided for by community doctors, dentists and nurses, midwives, health visitors, and members of other allied professions. It is health or social care and treatment outside of hospital, placed in the clinics, non-acute hospitals or in people's homes.