Health and Welfare

National Health ServiceWelfare StateJoy Johnson

texts

• Morrison • Coalition Agreement

Historical context

• National health Service (NHS) founded 1946• Mounting concern over inequality between richest

and poorest• Roots in the Liberal economist Beveridge Report and

Lloyd George (1911) of a National Insurance (NI) scheme (meant to insure low paid against sickness and unemployment)

• Doctors bought off• Legacy of consultants doing private work• NHS Free at the point of need

Post war – welfare state

• Beveridge report was the blueprint for the welfare state – NHS was part of it

• Clement Atlee’s 1945 reforming Labour government• Vision of Aneuring Bevin (Nye Bevin) – “We now

have the moral leadership of the world”.P 179 Morrison

• free at the point of need but by 1951 charges introduced – prescriptions, opticians, dentists

• Led to high profile resignation including Nye Bevin

Funding of the NHS

• Proportion of GDP varied widely• Labour invests heavily in NHS• Conservative complaint that it is inefficient• Funded out of general taxation (80%) – income tax and

indirect taxes• Remaining 20% National Insurance contributions• Charges to patients for drugs (prescriptions) and

treatment• Income from variety of sources including land sales• Voluntary fund raising

End of post-war consensus

• Structure and funding remained the same for forty plus years

• NHS political battleground• Reforms instituted since late 1980s• GPs self employed• Specialists work as freelance locums moving from

hospital to hospital• Junior doctors, nurses and care workers – agency

working• Catering, cleaning and security out-sourced

End of post-war consensus

• Internal market• Thatcherite reforms saw management structures set up with

generalists appointed to sit alongside clinical staff• Introduction of general managers to run District Health

Authorities (DHAs) funds directed to local hospitals and surgeries

• Community based health care with GPs , dentists, and other primary care providers given control of budgets - attempt to end ‘one size fits all’ approach to targeted approach

• Department of Health and Social Security (DHSS) split into Department of Health and Department of Social Security

• Further reforms under John Major created NHS trusts

Private health care

• http://www.youtube.com/watch?v=iTFBXMiYU8w

NHS trusts

• Hospitals mental health units ambulance services and others directly involved make up NHS trusts with own management boards (practitioners and general managers)

• GPs offered opportunity to become fund holders – could opt out of district health authorities

• GP fund-holders, DHAs and family health service authorities (FHSAs) became purchasers of NHS primary care

• NHS trusts were defined as providers

That was the theory what happened in practice

• Not all GPs wanted to go down this route – by the time Labour came into power 1997 fewer than half had signed up

• Internal market criticised for being too concerned with management - more interested in flow charts

• Major criticism – post code lottery

Criticism

• Post Code Lottery• Waiting lists increased – horror stories in the

press and broadcasting • By May 1997 1.3m people waiting for

treatment and operations • Cancelled operations • Stories of elderly and vulnerable falling ill and

dying while waiting for treatment

Blair and NHS

• Blair’s political campaign – 24hours to save the NHS

• Cut waste• Cut waiting times• In government set targets

New Labour restructuring

• NHS Act 1999• Primacy of community based health care• Established primary care groups to be replaced by

primary care trusts (PCTs) purchase clinical services (commissioning)

• Strategy health authorities (SHAs)• Great emphasis on targets• Foundation Hospitals• Patient Choice

NICE

• National Institute for Clinical ExcellenceExecutive agency of the NHS. • Guidance on prevention • Advising governments on whether new and

existing clinical treatments, medicines and produced should be made or remain available on the NHS

Back Door Privatisation

• Political battleground even within own party• Labour backbenchers rebelled over Alan

Milburn’s Ten Year Plan• Public Private partnership PPPs• GPs botched contracts

GPs’ contracts

• Tony Wright respected former MP and chair of the Public Administration Select Committee on GP contracts largely regarded as botched:

• Can it be true that we had to pay GPs a lot more money to do a lot less work and now we have to pay them a lot more money to take on the work that we paid them to stop doing?"

http://www.dailymail.co.uk/news/article-432833/Labour-MPs-challenges-Blair-GPs-contracts.html#ixzz1GJS4GjPC

Coalition government

• Not in the agreement but major re-organisation by Andrew Lansley

• Agreement said: ‘We will stop the top-down re-oganisation of the NHS that have got in the way of the NHS’

• We will ensure that there is a stronger voice for patients locally through directed elected individuals on the boards of their local Primary care trust (PCTs)’

Coalition Agreement p 24

In fact

• Pct’s to be abolished• GPs to be given 81 billion budget

Lansley and re-structuring

• http://www.telegraph.co.uk/news/newsvideo/uk-politics-video/8203329/Andrew-Lansley-pledges-clinically-led-NHS.html

Issues

• Lansley re-organisation• Passage through the House: Liberal Democrat

spring conference 12.311 passed critical motion led by Shirley Williams (Observer 13.3.11). As the NHS reorganisation wasn’t in coalition negotiations amendments to be laid to the plans to avoid ‘privatisation’

• Budget cuts (meant to be ring-fenced)

Welfare State

• National Insurance (progressive tax) – Lloyd George 1909 bedrock of the welfare state

• 30% of GDP • Social security system• Department of Work and Pensions• Unemployment • Job Seekers Allowance• Youth unemployment – New Labour New Deal • Executive Agencies administer complex benefits

system

Executive Agencies

• Jobcentre Plus• Child Support Agency• Pension Service

Types of benefit

• Contributory benefits – related to contributions made through NI contributions i.e. Jobseekers allowance and incapacity benefit

• Non contributory benefits – based on needs (income falling below a certain level based on criteria

• Means testing• Income support – various rates• Child benefit

Welfare Reform Bill

• Ian Duncan Smith Sec of State for Work and Pensions in coalition government steering through the Welfare Reform Bill in the Commons

•

State Pensions

• State pension foundation of the welfare state(from cradle to grave)• National Insurance contributions (women taking

time out for families – problem of pensioner poverty)

• Topped up with income support where necessary• Attempts at reform across political spectrum• Womens’ retirement age going up to 65 to

equalise with men

Types of pensions

• State retirement pension – contributory value plummeting

• Stakeholder pension – not private hybrid• State second pension – replacement for SERPS(see Morrison p 256 full explanation)• State pension link to earnings

Ian Duncan Smith on making work pay

• http://www.bbc.co.uk/news/uk-politics-11728546

Welfare Reform Bill

“Make provision for universal credit and personal independence payment to make other provision about social security and tax credits; to make provision about the functions of the registration service, child support maintenance and the use of jobcentres and for connected purposes.”

Simplifying the system

• Work Secretary Iain Duncan Smith plans to bring in a single Universal Credit to replace six income-related work-based benefits.

• Mr Duncan Smith argues that millions of people have become trapped on benefits.

• nearly 1.1 million workless households, a person will currently lose more than 70% of their earnings if they move into work of 10 hours a week, the government claims.

• people are always better off in work than they would be on benefits.

Provisions of the Bill• It will start for new claimants in October 2013, with people migrating over from

existing benefits during the following four years.• could take 10 years to come into effect fully.• stricter rules for people losing their benefits if they refuse a job, under the

plans. A sliding scale of sanctions will see benefits withdrawn for three years if three jobs are refused in three years.

• those who refuse work on one occasion in 12 months having their benefits taken away for three months. If they refuse a second job within the next 12 months, benefits will be taken away for six months. If they refuse a third job in the next 12 months, their benefits will be taken away for three years.

• The government plans to replace Disability Living Allowance with the Personal Independence Payment from 2013.

• This tax-free benefit is paid to 3.2 million disabled people, including children, who may need care for a physical or mental disability and need somebody to help look after them.

Political battleground

• Welfare Bill had its second reading • Watch for amendments• Campaign groups – incapacity benefit• Child credit

Reform of Public Sector Pensions

• John Hutton (former Labour cabinet Minister proposals for reform published 10.3.11)

• http://www.bbc.co.uk/news/business-11466273

Hutton explained – expect most of his report to be adopted

• The most significant recommendation is that existing pensions should be changed from a final-salary basis, to a pay-out based on average pay over workers' careers.

• Lord Hutton says this would be possible to carry out by the end of this Parliament, in 2015. However, the switch could take longer for some schemes, such as the police and armed forces pension schemes.

• raise the age at which people are entitled to draw their pension to the same as the state pension, Plans are for the state pension age to reach 66 for both men and women by April 2020.

• Uniformed services - the armed forces, police and firefighters - should see their pension age rise to 60, Lord Hutton says.

• cap on the cost of public sector pensions to the taxpayer. Simplifying

Seminar questions

• Describe the structure and management of the NHS; NICE; Primary Care Trust; NHS trusts; Foundation trusts

• Issues?• How would Lansley’s reorganisation affect these• Welfare – outline the organisation and administration

of social welfare services including distinguishing between contributory and non contributory benefits and the role of the National Insurance Scheme

• Issues• How will Welfare Bill change things

Next week

• Devolution in the UK