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IV. WELFARE STATE
- The National Health Service
- The Social Security System
- Personal Social Services and Charities
Welfare
Britain can claim to have been the first large country in the world to have accepted that it is part of the job of government to help any citizen in need and to have set up what is generally known as a 'welfare state'.
The origins of the welfare state in Britain
Before the twentieth century, welfare was considered to be the responsibility of local communities. The 'care' provided was often very poor. An especially hated institution in the nineteenth century was the workhouse, where the old, the sick, the mentally handicapped and orphans were sent. People were often treated very harshly in workhouses, or given as virtual slaves to equally harsh employers.
During the first half of the twentieth century a number of welfare benefits were introduced. These were a small old-age pension scheme (1908), partial sickness and unemployment insurance (1912) and unemployment benefits conditional on regular contributions and proof of need (1934). The real impetus for the welfare state came in 1942 from a government commission, headed by William Beveridge, and its report on 'social insurance and allied services'. In 1948 the National Health Act turned the report's recommendations into law and the National Health Service was set up.
The mass rush for free treatment caused the government health bill to swell enormously. In response to this, the first payment within the NHS (a small fixed charge for medicines) was introduced in 1951. Other charges (such as that for dental treatment in 1952) followed.
The health and social welfare system is part of everyone's life in Britain. It provides help for anyone who is raising a family or who is elderly, Sick, disable, unemployed, widowed or disadvantaged.
Everyone at some point in their lives will receive help from its varied services, ranging from health checks for children, home help for disabled or elderly people or cash benefits to cover periods of unemployment.
The three pillars of the health and social welfare system are:
The National Health Service - the health of the community is the responsibility of the NHS, free to everyone who normally lives in Britain.
The Personal Social Services - provided by local authorities for elderly and disabled people, those with mental disorders and for families and their children.
Social Security - designed to secure a basic standard of living for people who are unemployed, help for families and help towards the coast of disablement.
The National Health Service
The NHS is a central element of the welfare state, present on virtually every high street in the form of local pharmacists and in every community and neighbourhood in the form of General Practitioners (GPs) and dental services.
On a typical day in England, nearly three quarters of a million people will visit their doctor and one and a half million prescription items will be dispensed by pharmacies. Ambulances will make 8,000 emergency journeys, 2,000 babies will be delivered, 90,000 people will visit a hospital outpatient clinic and more than half a million households will receive help in the home.
The NHS which provides all these services has a yearly budget of more than ₤41 billion. With one million staff, it is one of the largest employers in the world.
The principles on which it was founded at its creation in 1948 remain true today: that there should be a free, comprehensive health service for everyone according to need, regardless of their income.
What does the NHS do?
The aims of the NHS are clear. They are to improve the health of the nation as a whole by:
• promoting health
• preventing ill health
• diagnosing and treating injury and disease and
• caring for those with long-term illness and disability.
To achieve these aims, the NHS provides a comprehensive range of care, nearly all of which is free:
• primary care through family doctors, dentists and other health care professionals
• secondary care through hospitals and ambulance services
• tertiary care through specialist hospitals treating particular types of illness or disease.
The NHS also collaborates with social services to provide community care.
Primary care
The vast majority of people are seen by primary care services in the community. They remain the first point of contact most people have with the NHS: between them they cater for about 90 per cent of patient contact with the health service, at half the cost of hospital care. The Government's long-standing policy is to build up and extend these services to relieve the more costly secondary care services of hospital and specialist services.
Primary care is provided by family doctors, dentists, opticians and pharmacists, who work within the NHS as independent practitioners. Other professionals involved in primary care include district nurses, health visitors, midwives, speech therapists, physiotherapists, chiropodists, dieticians and counsellors.
GPs or family doctors are present in every community and they remain the backbone of the health service. They provide essential primary care and act as gatekeepers to other services, referring patients on when necessary. Every year there are some 250 million GP consultations and some six million people visit a pharmacy every day.
Visits to doctors or dentists may be for treatment or for preventative advice. Preventing ill-health is an important part of a GP's work, and most GPs run programmes to prevent heart disease and stroke, to manage chronic diseases such as asthma and diabetes and to improve childhood immunisation rates.
About 80 per cent of GPs work in partnerships or group practices - often as members of primary health care teams. Primary health care teams also include health visitors, district nurses and midwives who are salaried NHS staff, and sometimes social workers and other professionals employed by the health authorities. GPs often work in health centres which offer people a range of health services in one place.
Other key primary care professionals include:
midwives who care for women throughout pregnancy, birth and for 28 days after the baby is born. Some are based in hospital and some go out into the community.
health visitors who promote health for families and are responsible for preventative action. They aim to identify the health needs of the local population and work closely with other NHS colleagues.
district nurses who care for people in their homes or elsewhere outside the hospital setting. Like health visitors, they offer advice in health promotion and education.
How primary care is developing
The 1997 NHS Primary Care Act introduced greater flexibility in the delivery of primary health care services for patients. The new law allows GPs, dentists, NHS trusts and NHS staff to develop, with health authorities and health boards, new ways of delivering their primary care services.
From October 1998 pilot schemes began in areas with high levels of illness and where it is often difficult to recruit GPs. There are two types of scheme:
• one which will enable NHS trusts or GP practices to employ GPs on a salary (instead of a self-employed basis), with the aim of giving patients who live in areas of high health risk access to a flexible family doctor service;
• one to create primary health care 'one-stop shops' where GPs, community nurses and other professionals work as a single team in the community offering a range of services from eye tests to counselling.
The new Primary Care Groups - local partnerships between family doctors and community nurses - will be expected to play an increasing role in taking decisions about services for patients.
Secondary care
While Primary Care Groups may be the first point of call, secondary care, managed by NHS Trusts, deal with any further treatment or care someone may need. This can range from health advice to some of the most sophisticated treatment in the world.
There are around 300 district general hospitals in England, found in many large towns and cities. They provide a range of services from the care of the elderly to maternity services, supported by services such as anaesthetics, pathology and radiology. Almost all district hospitals have accident and emergency departments for emergency admissions.
Patients either attend as day cases, in-patients for a longer stay or out-patients. There are also patients who attend wards for treatments such as dialysis. The advent of new treatments has meant the trend has been towards more patients treated as day care and fewer long-stay wards.
Tertiary care
Some hospitals provide specialist services such as heart and liver transplants, treatments for rare cancers and craniofacial services. These specialist services cover patients over more than one district or region.
There are also specialist hospitals of international renown such as the Hospital for Sick Children at Great Ormond Street, Moorfields Eye Hospital and the National Hospital for Neurology and Neurosurgery. As well as offering highly specialised treatments, these hospitals are also centres for teaching and international research.
Hospital building under the Private Finance Initiative
The Government wants to promote a partnership between the public and private sectors in many areas of industry and services. The Private Finance Initiative (PFI) was launched in 1992 for this purpose: in the health service it means encouraging private companies to help finance the design, construction and running of NHS buildings and support services.
In May 1997, in order to boots the PFI, the new Government passed legislation which made the powers of NHS Trust clearer when signing PFI agreements. Further schemes costing ₤2,500 million have since been announced, amounting to the biggest hospital building programme in the history of the NHS.
Community Care
Social services have the lead responsibility for community care services to meet the needs of older people, people with disabilities, mentally ill people or other vulnerable members of society. The NHS, however, has an important role in providing some services and in collaborating closely with social services to plan and deliver community care.
Here the role of the NHS includes helping to assess people's needs for community care, liaising with social services over hospital discharges to make sure people get the continuing care they need, as well as delivering some services. The NHS makes an important contribution to community care services, for example, district nurses provide nearly 2.5 million episodes of care annually.
How is the NHS funded?
The NHS is free at the point of delivery to anyone normally resident in Britain. All taxpayers and employees contribute to its cost.
About 82 per cent of the coast of the health service is paid for by general taxes. The rest comes from:
• a proportion of National Insurance contributions (paid by working people and employers) - 12.2 per cent
• charges towards the costs of certain items, such as drugs prescribed by GPs, dental treatment and sight tests - 2.3 per cent. (Children and adults who may have difficulties paying are exempted from these charges.).
• land sales and other schemes for generating income - less than one per cent.
In addition:
• health authorities are free to raise funds from voluntary sources and
• some NHS hospitals take private patients who pay the full cost of their accommodation and treatment.
How is the money spent?
The NHS is one of the largest employers in the world, and staff costs account for two-thirds of all expenditure. About one tenth of the budget, some ₤4 billion, is spent each year on medicines.
In terms of spending on patients, more than two-fifths of total hospital and community health services expenditure, is on people aged 64 and over, while they make up just 16 per cent of the population.
The pie chart on the left shows spending in terms of different services:
• Hospital and Community Health Services provide hospital care and a wide range of community services
• Family Health Services (FHS) provide general medical, dental, pharmaceutical and some ophthalmic services, and covering the cost of medicines prescribed by GPs
• Central Health and Miscellaneous Services provide services which are most effectively administered centrally such as welfare food (such as free milk and vitamins for the children of families on Income Support) and support to the voluntary sector
• The administrative costs of the health departments are included under Departmental Administration.
Increased spending
Spending on health is one of the Government's top priorities. Spending on the NHS has increased in real terms for many years: the total in 1996-1997 was ₤35 billion; in 1997-1998 this figure increased to nearly ₤42 billion, which amounts to ₤1,700 for every household in the country.
In July 1998 the Government announced it would provide an extra ₤20 billion over the next three years. That amounts to an increase of 4.7% a year above inflation between 1998-1999 and 2001-2002.
This investment in the NHS is planned to bring a host of improvements to services:
• improve hospitals and GP services
• provide for the largest hospital building plan ever
• reduce waiting lists
• finance reform, based on partnership of all health bodies, with GPs and nurses playing a more important role
• begin to reduce avoidable illness, disease and injury and
• reduce the rate of growth in emergency admissions.
How is the NHS organised?
Central Government is directly in charge of the NHS, led by the Secretary of State for Health and a team of ministers at the Department of Health. The Department is responsible for planning a health strategy in England.
Within that department, management of the service is led by the NHS Management Executive. The NHS Management Executive is responsible for developing policies which ensure the quality of health services. The Executive has eight regional offices, which liaise with the health authorities in their region.
Services are administered by a range of health authorities and health boards throughout Britain. There are 100 health authorities in England and five in Wales, 15 health boards in Scotland and four health and social services boards in Northern Ireland. They are all responsible for identifying the health care needs of the people living in their area. They also arrange for services from doctors, dentists, pharmacists and opticians and administers their contracts.
Community health councils (local health councils in Scotland) represent the opinion of local people on the health services provided and on any planned changes.
Health authorities and boards cooperate closely with the local authorities in charge of social work, environmental health, education and other services.
Recent reforms
The new Health Act 1999 encourages partnership within the NHS and between the health service and local authorities to improve health care, and has created two bodies to drive quality in the NHS. Its main aspects are:
• the creation of Primary Care Groups and Trusts, teams of GPs, community nurses and social services staff, to take control of most of the NHS budget from April 1999. The new teams put local doctors and nurses in the driving seat in shaping local health care;
• new powers to break down barriers between health and social services and between the NHS and local authorities, to encourage partnership working and deliver health improvements;
• the introduction of new legal duties of quality of care and of partnership to drive up standards of care;
• two new national bodies, the National Institute for Clinical Excellence and the Commission for Health Improvement, to encourage best practice, spread good-value new treatments across the NHS and sort out problems - all to improve quality;
• Health Action Zones, formed in some of the most deprived areas of the country and covering some 13 million people, which will tackle health problems of local people;
• NHS Direct - a 24-hour telephone hotline staffed by nurses to help reduce pressure on hospitals and GPs by giving on-the-stop health advice.
NHS staff
The NHS is Europe's largest employers with a workforce of nearly one million people. Nurses and midwives make up nearly half the entire workforce in England. Staff costs account for roughly 70 per cent of spending on hospitals and community health services.
The numbers of GPs in England has risen by nine per cent between 1987-1997, with all of the increase occurring amongst women. The numbers of ancillary and maintenance and works staff directly employed by the NHS has fallen since the introduction of competitive tendering which has led to many of these jobs being carried out by the private sector.
In September 1996 approximately 940,000 non-medical staff were employed in the NHS hospital and community health services:
• 67 per cent of these staff were directly involved in patients care and 33 per cent were management and support staff
• there were 332,660 nurses, midwives and health visitors
• there were 167,430 administration and estates staff
• just under 80 per cent of the non-medical workforce were female and over five per cent were from ethnic minority groups.
Family doctors
There were 28,937 GPs in England in October 1997. By 1996, nearly a third were female, compared with just over a fifth in 1986.
The contribution made by the Voluntary Sector
The voluntary sector plays an important role in supporting patients and health services. The Government gives grants to a large number of voluntary organisations working in health and personal social services in recognition of the valuable work they do.
The money - ₤59 million in 1996-1997 goes mainly to national organisations dealing with:
children people from ethnic minorities
older people people with HIV/AIDS
carers people suffering from drug or alcohol misuse.
In Scotland, Government grants for 1996-1997 amounted to ₤9 million. In Northern Ireland the Department of Health and Social Services spent ₤6.4 million in 1996-1997 to support voluntary work in the health service.
Private medicine
About 11 per cent of the population in Britain is covered by private medical insurance and it is estimated that about three quarters of people receiving treatment in private hospitals or NHS pay beds are funded by health insurance schemes.
NHS patients are occasionally treated in the private sector (at public expense) in cases where doctors and managers consider it will be good value for money. The scale of private medicine compared to the NHS, however, is small.
Many overseas patients come to be treated in British private hospitals: Harley Street in London is world famous as a centre for medical consultants.
Personal Social Services
Social services provide ₤10 billion worth of care a year to vulnerable or disadvantage members of society. They cover the whole age range to provide for the poorly cared-for child to people who are approaching the end of their life. In between they care for people with mental health problems, physical disability or learning disabilities.
Personal social services are the responsibility of local social services authorities in England and Wales, social work departments in Scotland and health and social services boards in Northern Ireland.
The main services they provide are:
• residential care
• day care
• services for those confined to home and
• various forms of social work.
Social Services spending
• In 1997-1998, current expenditure in England on Personal Social Services was ₤10 billion, or about ₤200 per head
• Services for children and older people accounted for nearly three-quarters of spending
• The single biggest item of expenditure was residential care for older people
• All but two per cent of the remainder was for people with a mental illness, or physical or learning disabilities
• Spending on residential services accounted for just under half of the total
Modernising Social Services
In November 1998 the Government announced a new ₤3 billion programme to reform social services in a White Paper Modernising Social Services. The Paper proposes ways of making sure local councils, the NHS, voluntary bodies and commercial providers work together to deliver improvements, which include:
• promoting chances for people to live independent, fulfilling lives
• improving the protection of vulnerable people
• raising the standards of services
The White Paper introduces plans for:
• a commission for care standards, an independent watchdog for each English region to regulate services whether they are provided in people's own homes, through organisations such as fostering agencies or in residential homws
• new national standards of performance for local authorities and annual reports an what councils have achieved or not achieved
• children's rights officers to inspect children's homes
• the General Social Council, whose job will be to ensure the proper regulation and training of all the social care workforce
Family and voluntary carers
Much of the care of older and disabled people is provided by the community - by families, self-help groups and voluntary agencies, leaving the statutory sector to provide the skilled care needed in particular services. There are about seven million such carers - one in eight adults in Britain.
The Government acknowledges the crucial role of carers. People who provide substantial, regular care have a right to have their own needs for help assessed. The Government also plans to create a national strategy for carers which will focus on recognising the importance of their role, consulting them and supporting their essential work.
There are nearly 200,000 voluntary organisations and charities concerned with health and social welfare. They range from national bodies such as Help the Aged to small, individual self-help groups. As demand for personal social services growth the contribution of the voluntary sector is also becoming increasingly important.
Meeting increasing demand
The demand for social services is increasing became of the growing numbers of older people and opportunities for older, disabled, mentally ill people and those with learning difficulties to live in the community, supported by health and social services.
Older people
Most older people continue to live in their own homes, with appropriate help. Only a small number - some five per cent - of people over 65 live in residential accommodation. In February 1999 the Royal Commission on Long-Term Care reported on the future of care for the elderly. The Government is consulting on its recommendation that the costs should be sharted by the individual and the State.
Services for older people, whether statutory or voluntary, are designed to help them live in their own home whenever possible. The services provide include help in the house, meals brought to the home, laundry services, sitters-in and night attendants. There are also day centres, luncheon clubs and recreational facilities which they may travel to.
Equipment, aids and adaptations to the home are available to help older people manage in their own homes. A special alarm system, for example, is provided by the local authority which allows older people to summon help in an emergency. Some local authorities or voluntary organisations run visiting services to check on the welfare of older people in the neighbourhood.
The trend in residential care for older people has been away from homes provided by the local authority towards greater numbers of places in private and voluntary-run homes. Local authorities do, however, have a duty to provide homes designed for older people. These are known as sheltered accommodation, and many have warders on site.
Transport for older people is often free or subsidised - paid for in either care by the local authority.
Disabled people
There are some six million adults in Britain who have one or more disability. Some seven per cent of these (about 400,000 people) live in communal establishments. As part of the reforms of the early 1990s, there has been a trend towards supporting disabled people to live independently in their own homes, providing them with day and domiciliary services. Social services also provide respite care so that people who regularly care for disabled people can have a bread.
Local social services are required to identify the number of disabled people in their area and to publicise services. Services include advice and help to rehabilitate disabled people or help them adjust to a recent disability. They also cover day centres or other places where social, occupational, educational and recreational facilities are provided.
Specially-designed housing may be available for those able to look after themselves, or adaptations to the home can be made by social services, for example, ramps for wheelchairs or stair lifts.
People with learning disabilities
Social services are the lead statutory body for planning and arranging services for people with learning disabilities. The help they provide or arrange includes short-term care, support for families in their own homes, residential accommodation if a person needs it and activities outside the home.
People with learning disabilities are the largest group for day centre places funded by local authorities and the second largest group in residential care. If person has profound disabilities, the NHS will look after them in residential care. The NHS also provides specialist help if someone with learning disabilities needs it.
The Government aims to help people with learning disabilities lead full lives in their communities, and only be admitted to hospital on health grounds. In local settings, social services work with the NHS, families, education and training services and voluntary groups to plan and provide a range of services.
Help for families and children
Social services have a duty to look after the welfare of any child in need. They either provide directly or arrange for a range of help to families in crisis. This includes advice, counselling, help in the home or access to family centres. Sometimes services are provide by voluntary groups, for example refuges which provide a safe base for women and children who suffer domestic violence.
If a child is considered at risk of neglect or of physical, mental or emotional abuse, he or she is placed on a child protection register so the situation can be monitored. At the end of March 1996 some 32,000 children were on registers. A number of agencies and professions - co-ordinated by area child protection committees - are responsible for children at risk.
Children whose parents are unable or unwilling to look after them are placed in the care of the local authority who act as the legal guardian. The law requires that whenever possible children should remain with their families. However, if they are likely to suffer significant harm at home, children can either be placed in the care of foster parents or in a children's home with others. Children's homes are run by local authorities, voluntary or private organisations.
In September 1998 the Government launched the Quality Protects programme, a three-year strategy underpinned by ₤375 million, to improve children's services and deliver nationally agreed outcomes for children in care.
Social Security
The Department of Social Security is the biggest spending department of government and a major pillar of the welfare state. It provides more than ₤92 billion of benefits to secure a basic standard of living for people who are retired, unemployed or cannot work, to provide help for families and with the costs of disablement.
What is social security for?
The social security system provides a minimum level of income below which no-one should fall if they are unable to work through their circumstances, unemployment, or disability. Social security provides cash benefits for children and families, unemployed people, disabled people and pensioners, including war pensioners.
The Government wants the welfare system wherever possible to help people towards independence, not to encourage dependence. The Government sums up its aims for social security like this: work for those who can; security for those who cannot. Later on this section describes the Government's plans for reform and the measures to help people into work.
How is social security funded?
All taxpayers, employers and employees contribute to the cost of social security. The programme has two sources of finance.
• The cost of contributory benefits and their administration is met from the National Insurance Fund, to which all employers and employees contribute. The Fund also has income from its investments.
• Non-contributory benefits and their administration are financed from general taxation.
General taxation provides more than half of social security income, National Insurance contributions from employers around a quarter and National Insurance contributions from employees about a fifth.
How is the money spent?
The total social security budget in 1997-1998 was more than ₤ 92 billion, which is almost a third of all government spending. The pie chart top left show how the budget was spent on people who received benefits for the year 1997-1998. The pie chart bottom left shows how the money was spent in terms of benefits for the same year.
Who receives benefits?
More than 20 million people receive some sort of benefit in Britain. The elderly and the short-term sick receive predominantly contributory benefits, unemployment people receive mainly income related benefits, families mainly other benefits while the long-term sick and disabled receive all three types of benefit.
Benefits and who receives them
Group Benefit
Elderly people Retirement Pension
Non-contributory Retirement Pension
Christmas Bonus
The principal income-related benefits
Winter Fuel Payment
Long-term sick and disabled people Incapacity Benefit (long-term rate)
Attendance Allowance
Disability Living Allowance
Disability Working Allowance
Industrial Injuries Disablement Benefit
Other Industrial Injuries Benefit
Severe Disablement Allowance
Invalid Care Allowance
War Pensions
Independent Living Fund
Motability
Christmas Bonus
Principal income-related benefits
Short-term sick people Statutory Sick Pay
Incapacity Benefit (short-term rate)
Principal income-related benefits
Families Child Benefit
Family Credit
Statutory Maternity Pay
Maternity Allowance
Maternity Grant
Principal income-related benefits
Unemployed people Unemployment Benefit
Jobseeker's Allowance
Principal income-related benefits
Widows and others Widow's Benefits
War Widow's Pensions
Guardian Allowance and Child's Special Allowance
Industrial Death Benefit
Social Fund Funereal Payments
Earnings Top-up Pilots
Income support paid to people who do not fall within the other client groups
How is Social Security organised?
The Department of Social Security (DSS) comprises a small central headquarters which support the Secretary of State for Social Security and a team of Ministers in developing policy, and five executive agencies. Most of the services in Great Britain are run by the separate agencies.
Executive agencies of the DSS
The Benefits Agency - pays most social security benefits
The Child Support Agency - collects child maintenance from absent parents
The War Pensions Agency - administers benefits and delivers services for war pensioners and their dependants
The Information Technology Agency - develops, implements and supports the IT system which now plays a major role in social security
In Northern Ireland the Social Security Agency administers contributions and benefits.
Types of benefit
There are three broad categories of social security benefit:
Contributory benefits, where entitlement depends on a person's record of National Insurance contributions. The main contributory benefits are Retirement Pension, Widow's Benefits, Incapacity Benefit and Jobseeker's Allowance. These account for half of social security spending.
Income-related benefit, for people whose income falls below a certain level, determined according to their family circumstances. These benefits take a person's capital well as their income into account. The income-related benefits are Income Support, Housing Benefit, Council Tax Benefit, Disability Working Allowance, Family Credit and Earnings Top-up in certain pilot areas. These account for a third of social security spending.
Jobseeker's Allowance has both contributory and income-related components.
Other benefits depend on conditions such as disability or family needs. Benefits in this group include Industrial Injuries Disablement Benefit, Attendance Allowance, Disability Living Allowance, Severe Disablement Allowance and Child Benefit. These other, non-contributory benefits account for about a sixth of social security spending.
The Government's aims
Since taking up office in May 1997 the Government has announced a number of wide-ranging reviews with the key objectives of tacking unemployment and social division which excludes people from playing a full part in their communities. The aims of the reviews are to:
• modernise the structure of social security and the way benefits are delivered to encourage financial independence and promote social cohesion
• make the welfare system active in supporting work, saving and honesty
• tackle social and economic inequalities.
Welfare Reform
Welfare reform is central to the Government's plans for the future development of Britain. Reform will tackle three key problems with the existing welfare system:
• inequality and social exclusion are worsening, especially among children and pensioners, despite rising spending on social security;
• people face a series of barriers to paid work, including financial disincentives; and
• fraud is taking money out of the system and away from genuine claimants.
Reform will be a long process, but the Government has already begun by publishing a Green Paper on Welfare Reform entitled New Ambitions for Our Country - A New Contract for Welfare. It sets out a number of key principles guiding welfare reform and includes a series of success measures to be achieved over the next 10 to 20 years. For example, by the end of the process of reform, the results that the Government expect to achieve include:
• a reduction in the proportion of working age people living in households where no-one works
• a guarantee of decent income in retirement for all
• a reduction in discrimination against people and an increase in the number of disabled people at work
• a rise in the proportion of parents meeting their financial obligations to children after separation
• a reduction in the amount of money lost in fraudulent payments.