NATIONAL QUALIFICATIONS CURRICULUM SUPPORT
Modern Studies
Social Issues: Health and Wealth
Inequalities in the UK
[HIGHER]
George Clarke
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Acknowledgements
Learning and Teaching Scotland gratefully acknowledge this contribution to the
National Qualifications support programme for Modern Studies.
The following sources are thanked for permission to use copyright material in this
publication: text extracts on pp56/57 on Sure Start Scotland are from
www.surestart.gov.uk reproduced by permission; extracts on pp60/62 and 63/6 from
‘Changing Poverty Post-1997’ (2003) and ‘Routes into and out of Poverty’ (2004)
are from Findings: Progress on Poverty 1997 to 2003/4 , published by the Joseph
Rowntree Foundation and reproduced by permission
(www.jrf.org.uk/knowledge/findings/socialpolicy/043.asp and
www.jrf.org.uk/knowledge/findings/socialpolicy/n94asp ); text extracts on pp70/74
on the NHS are from www.nhs.uk/england/AboutTheNhs/Default.cmsx and
reproduced by permission.
© Learning and Teaching Scotland 2006
This publication may be reproduced in whole or in part for educational purposes by
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Contents
Section 1:
Background
4
Section 2:
Changes in class structure
8
Section 3:
Causes of inequalities in wealth
10
Section 4:
Inequalities in health
35
Section 5:
Health care and social welfare: the political debate
46
Section 6:
Policies to deal with wealth inequalities
48
Section 7:
Policies to deal with health inequalities
68
Resources: Useful websites
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BACKGROUND
Section 1
Background
Why define social class?
150 years ago sociology sought to develop a scientific approach to the study
of society. It needed methods of measuring society if it was to be accepted as
a science. In the nineteenth century, Karl Marx and Max Weber pioneered
models for defining class and structuring society so that it could be studied.
In Britain in the twentieth century the government us ed three models: the
Registrar-General’s Model of Social Class (RGSC), which was replaced by
the Standard Occupational Classification and, from 2001, the National
Statistics Socio-economic Classification.
Recently sociologists have developed alternative models. Two of the more
widely used are Hutton’s 30:30:40 and the Runciman Scale.
Defining social class involves measuring economic, political and social
factors, which is difficult. To simplify matters occupation has been used to
group people. However occupation does not provide a precise method of
measurement and at best only broad generalisations can be made from its use.
In contemporary Britain there are significant differences in life chances,
living standards and the quality of life between differen t groups. For example
the children of unskilled labourers are 4 times more likely to die in an
accident, suffer from poorer health and higher infant mortality rates and
attain lower levels of education compared with the children of professional
people.
Therefore, although defining social class may be difficult, it is a useful tool
for those involved in academic, business and government research. It
provides a way to analyse the population, to understand how groups of people
develop and change, and to help with planning for the future.
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BACKGROUND
The Registrar-General’s Model of Social Class (RGSC)
UK governments used this model between 1911 and 1980. It placed people
into a six-part hierarchy according to their occupation.
A
B
C1
C2
D
E
–
–
–
–
–
–
Professional etc. occupations
Managerial and technical occupations
Non-manual skilled occupations
Manual skilled occupations
Partly-skilled occupations
Unskilled occupations
The strengths of this model lay in the fact that it was simple to understand
and use. Statisticians were able to compare health, work, poverty and family
life through time, and this enabled governments to target resources for social
planning. However, the model had several weaknesses. It used only
occupation as a means of classifying people so i t missed out millions of
people such as those who were retired or unemployed or non -working
spouses. It also made no provision for those living on investments and
income from rent.
By 1980 another problem was that many jobs had changed in nature and
importance to society. After 1980, the UK government used the Standard
Occupation Classification (SOC). This had a classification based on nine
major groups that were divided into hundreds of subgroups matching most
occupations.
The nine major groups are:
1
2
3
4
5
6
7
8
9
Managers and Senior Officials
Professional Occupations
Associate Professional and Technical Occupations
Administrative and Secretarial Occupations
Skilled Trades Occupations
Personal Service Occupations
Sales and Customer Service Occupations
Process, Plant and Machine Operatives
Elementary Occupations
The advantage of this system was that it was more logically grouped than the
RGSC. Occupations were ranked according to the level of skill and the
qualifications needed to do the job. The system was also more objective than
the RGSC. However, it retained many of the weaknesses of the RGSC, such
as still focusing on occupation, and therefore missed out large numbers of the
population.
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BACKGROUND
In 2001 the National Statistics Socio-economic Classification was introduced
for all government statistics and surveys. It has eight classes, with the first
one subdivided into two.
1.1
1.2
2
3
4
5
6
7
8
Large employers and higher managerial occupations: company
directors, senior managers, senior civil servants, senior police officers
Higher professional occupations: doctors, lawyers, teachers and social
workers
Lower managerial and professional occupations: nurses, journalists,
actors, musicians, lower ranks in the police and armed forces
Intermediate occupations: clerks, secretaries, driving instructors,
telephone fitters
Small employers and own account workers: publicans, farmers, window
cleaners, painters and decorators
Lower supervisory and technical occupations: printers, plumbers,
television engineers, butchers
Semi-routine occupations: shop assistants, hairdressers, bus drivers,
cooks
Routine occupations: couriers, labourers, waiters, refuse collectors
Never worked and long-term unemployed: non-working spouses,
unemployed for various reasons
This system overcame some of the problems of the RGSC and the SOC. It
included large numbers of people who had been previously ignored such as
the unemployed, retired, spouses and students. It was also a more refined way
of categorising people. ‘Class’ now depends o n a combination of the type of
job and a person’s status within the job, such as an employer, self -employed,
a manager, a supervisor or an employee. So a self -employed joiner would be
in a different class from a joiner with 15 employees, and both would be in
different classes from an employee joiner, who in turn would be in a different
class from a supervisor of joiners. However, the system is still heavily based
on occupation and this remains a weakness.
Sociologists have also developed different ways of defining social class. Will
Hutton’s ‘The 30:30:40 society’ is based on Weber’s theory and argues that
modern society has created a two-tiered labour market. There are those
workers who are in full-time, well-paid and secure employment with high job
status. There is a second group consisting of part-time and casual workers,
who have little job security, low pay and low job status. Finally there are
those who are at the bottom of the hierarchy; they are unemployed and on low
incomes for a variety of reasons.
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BACKGROUND
Finally there is the Runciman Scale. The Runciman Scale combines the class
analysis of both Marx and Weber. It measures economic power, ownership
and control and includes an estimate of a person’s status based on their
marketability. The scale is based on economic power which has three
elements. First there is ownership. Does a person own a company? The
second is control. Does the person direct others in the workplace? Finally
there is marketability. What skills does a person have and to what extent are
these skills valued by society?
The strength of the Runciman Scale is that it uses several factors to analyse
class. Also it makes economic and status distinctions within the middle class,
to show the clear distinctions that exist within this class, and be cause this
class is extensive in modern society. Finally it attempts to define an
underclass to show that it is separate from the working class.
Activities
Make notes on social class in relation to the following themes:
• why it is difficult to define
• why trying to define it is necessary
• the value of a working definition for governments and sociologists.
This is necessary for understanding social class but it will not be
examined.
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CHANGES IN CLASS STRUCTURE
Section 2
Changes in class structure
There was significant structural change in occupational social class during
the twentieth century. The percentage of the workforce involved in manual
occupations was 75% in 1911 but this fell to around 38% in 1991 and has
continued to fall ever since. Manual occupations were replaced by a growing
number of managerial, professional and clerical jobs, and this upwards drift
in occupational mobility has continued since 1991.
Women have grown as a proportion of the workforce from 29% in 1900 to
46% in 2000. 5 million women were working in 1900. This increased to 13
million in 2000. This is one of the most significant changes in the
occupational class structure since 1900.
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CHANGES IN CLASS STRUCTURE
The diagram shows that the current class structure has over 50% of females in
work in the top three class categories with approximately 47% of males in
these categories. Fewer women are likely to be in manual jobs. Only 8% of
women are skilled manual workers compared with 27% of males, whereas
32% of women are employed in skilled non-manual compared with only 11%
of males.
Note that reasons for changes in class structure may be further explained in
the section on causes of unemployment, which examines various reasons for
structural changes to the economy.
Activities
1.
In what ways has class structure changed over the twentieth
century?
2.
Describe and explain the current trends in class structure.
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CAUSES OF INEQUALITIES IN WEALTH
Section 3
Causes of inequalities in wealth
Income and wealth
Income is the money a person earns in a given period. Income is in the form
of wages or salaries from employment, as well as interest from savings,
dividends from shares, profits from business, and rent from land and
property. Wealth is made up of the assets that are owned by people living in a
country. Wealth is in the value of a house, th e value of a pension, shares and
savings.
How wealth is held in the UK:
•
•
•
•
Housing
State pensions
Private pensions
Savings
The main sources of income in the UK:
•
•
•
•
•
•
Employment
Pensions
Benefits
Self-employed income
Rent, dividends, interest
Others
How wealthy is the UK?
The total value of all goods produced and services provided in a country in
one year is called the Gross Domestic Product (GDP). In order to compare
different countries, the GDP is divided by the number of people living i n the
country at the time. This is the GDP per head.
In 2003, the UK’s GDP per head was $25,500 (£17,340). This makes the UK
a very wealthy country. It is ranked 19th of 29 countries in the Organisation
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for Economic Co-operation and Development (OECD) and 24th in the world
overall (out of 192 countries).
Poverty in the UK
Absolute poverty is based on subsistence, a minimum standard needed to live.
UNICEF describe a person as living in absolute poverty if they are deprived
of two or more of the seven basic needs: clean water, sanitation, shelter,
education, information, food and health. If the household or individual does
not have access to a particular basic need, they are defined as ‘deprived’.
Relative poverty is when people do not get access to products and services
that society considers to be necessary for basic living. This type of poverty
varies significantly as society changes.
How do we measure poverty in the UK?
In Scotland the most commonly used definition of poverty is taken from the
low-income statistics produced annually by the Department of Social Security
in the Households Below Average Income (HBAI) publication. The HBAI
definition of poverty is 60 per cent of median income level. The median
income level is an average income measured as follows. The level of income
of each household is taken after direct taxes and benefits, adjusted for
household size; the median income level is the middle value, with half the
population above that level and half below it.
In 2003–04, according to the Department of Work and Pensions (DWP)
statistics, the median weekly income (before housing costs) for a single
person with two children was £359, and for a couple with two children it was
£490, so the poverty line for these two family groups was £216 an d £294
respectively.
Another method for measuring poverty is to use Income Support levels.
Income Support is paid to people in the UK who are not working and who do
not have to attend a Job Centre regularly. In 2005, the weekly Income
Support for a couple with two children was around £178; for a single parent
with two children it was £147.
In 1999, the Poverty and Social Exclusion (PSE) Survey identified those
items that the majority of the population thought were necessities. The
researchers chose 35 items considered by 50% or more of the people surveyed
as being necessary for modern living: for example, beds and bedding for
everyone in the household, two meals a day, the ability to celebrate a birthday
or Christmas. The researchers then identified how ma ny people had these
items and how many were unable to afford them. If a household could not
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CAUSES OF INEQUALITIES IN WEALTH
afford two or more of these things then they were classed as poor. The PSE
survey found that 26% were ‘poor’ because they lacked two or more items.
The extent of poverty in the UK
In 1979, 5 million people in the UK were classed as poor. Poverty grew
significantly through the 1980s and peaked in the mid 1990s at just over 14
million in 1996. Since then there has been some reduction to 12.4 million in
2003, but it has remained persistently high.
Today just less than 1 in 4 people in the UK – nearly 13 million people – live
in poverty. This includes nearly 1 in 3 children (almost 4 million) – using the
HBAI definition.
Which groups are vulnerable to poverty?
In 2002/03, 22% of the UK population (12.4 million people) were living in
low-income households. The trend is downwards from the 14 million in
1996/97. The reduction has been in low-income households with children and
low-income households with pensioners. In 1996/97, 4.3 million children
were in low-income households but this fell by 700,000 to 3.6 million in
2002/03 as a consequence of government policies on tax and benefits. The
number of low-income pensioner households fell during the same period by
500,000 from 2.7 million to 2.2 million.
In contrast, the number of working-age adults without dependent children in
low-income households was higher in 2002/03 than in 1996/97: 3.9 million
compared with 3.6 million. This group now accounts for a third of all p eople
in low-income households.
Who are the poor in Scotland? (average 2000/03)
Pensioners 17%
Working-age adults with
no children 36%
Children 27%
Working-age adults with
children 36%
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Since the mid 1990s, three groups – pensioners, children and working-age
adults with children – have all seen a fall in poverty rates. However, working age adults with no children have increased their likelihood of poverty and this
group now forms the largest group experiencing poverty in Scotland.
Activities
Make notes on:
•
•
•
•
•
•
•
how wealth is held in the UK
the main sources of income in the UK
to what extent is the UK a wealthy country?
absolute poverty
relative poverty
the level of poverty in the UK
the main groups vulnerable to poverty in the UK.
Practice essay
To what extent is poverty a problem in the UK?
(15 marks)
Poverty and social exclusion
Social exclusion embraces a variety of problems that lead to poverty. Social
exclusion describes the impact of the economic, industrial and social changes
that have taken place over the last 20 to 30 years. These include long -term or
repeated unemployment, family instability, social isolation and the decline of
neighbourhood and social networks. Social exclusion is a result of
shortcomings and failures in the systems and structures of family, community
and society.
Social exclusion occurs when people are separated from employment by
being unemployed, having poor skills or low income. It also involves
separation from social relationships, caused by the breakdown of the family,
which has led to an increase in single-parent families and more elderly people
with no family to care for them. Finally it involves alienation from social
systems such as education, decent housing and health services.
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To gain a clearer understanding of the concept of social exclusion, we shall
examine each of the main causes of poverty in turn, while examining the
interaction of education, health and housing and the overarching role that
government plays in these.
The main causes of poverty in the UK are:
•
•
•
•
•
•
Government policy
Unemployment
Low-income employment
Gender
Age
Race
Government policy as a cause of poverty
Government policy can have a significant impact on the levels of poverty and
also on the groups who are poor.
Between 1979 and 1997, Conservative governments made significant changes
in the structure of society and increased the gap between rich and poor,
thereby increasing relative poverty in the UK. Employment laws made it
easier for employers to dismiss workers and created higher levels of
unemployment. Union laws made it more difficult for trades unions to def end
workers’ wages and conditions.
The Conservative government sold off state-owned companies and privatised
health services and local government services, which created higher
unemployment and drove down wage rates. Throughout the period, benefit
levels were designed to encourage people back into employment. The policies
on taxation shifted the burden of tax from the rich to the poor.
Government policy on taxation continues to create poverty in the UK. Direct
taxes in the UK are lower than in almost ever y other country in Europe. On
average, UK employees pay 25% of their income in tax and National
Insurance, whereas in Germany, for example, employees pay 42%.
Corporation Tax is also lower in these countries than in the UK. However, the
overall tax burden in the UK is higher because of VAT and excise duties.
Therefore the burden of tax falls on the poor who have to pay a higher
proportion of their income in VAT than the well-off.
Between 1979 and 2005, the burden of taxation shifted from the rich to the
poor because less was collected in direct taxes such as income tax and more
was collected from VAT and excise duties. VAT rose from 8% to 17.5%, and
excise duties on fuel, alcohol, tobacco products, etc. also increased
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significantly. This helped increase the disposable income of the better-off at
the expense of the poor. This widened the income gap and created more
poverty in the UK. Since the mid 1980s, disposable incomes for males in the
top 10% increased by 80% whereas the increase for those in the bott om 10%
only increased by 10%. Therefore, since the mid 1980s, the gap between the
wealthiest and poorest earners in the UK has increased significantly.
Since being elected in 1997, the Labour Government has sought to get more
people off benefits (welfare) and into jobs (work). As part of its ‘Welfare to
Work’ programme it has sought to create a significant difference in the
incomes of those who are on benefits and those who are in work, in order to
encourage people from benefits and into jobs. To make work more financially
attractive it has introduced the National Minimum Wage, Working Tax Credit
and Child Tax Credit.
To make benefits less attractive it has reduced the amounts paid in benefit
relative to increases in earnings, it has reduced the time some one can remain
on benefit before they must find work or go into training and it has made it
easier for people to be removed from benefit.
Activities
Make notes on:
•
•
social exclusion
how governments can have an impact on poverty.
Unemployment as a cause of poverty
The nature and availability of employment is a factor that contributes to
poverty in the UK. If there are enough well -paid jobs in a community then
there will be far less poverty. However, if there is an increase in
unemployment or low-paid and part-time employment, then poverty will
increase.
Measuring what is meant by unemployment is a problem. Between 1979 and
2000, there were 30 major changes in the ways that unemployment was
measured in the UK. Most of these changes reduced the une mployment total.
When Labour came to power in 1997, it said it would use the method used by
the International Labour Organisation (ILO), which tries to measure everyone
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who says they are looking for work, not just those who are eligible for
unemployment benefits.
However, the unemployment total does not include people who are on
training and employment schemes or who have been removed from the New
Deal because they are over 55 or are lone parents. In addition many people
who work part-time would prefer full-time jobs. These people form the
‘hidden unemployed’. They include men who have retired early under
disability provisions and young people forced into further and higher
education because they cannot find jobs.
Another way to measure employment and unemployment is to turn the figures
around and measure labour force participation rates. These measure the
percentage of the population between 16 and retirement age who are working
or actively seeking employment. In 2004, the participation rate was 74.7%,
which was 28.5 million people. By 2005, it rose to 28.8 million. This figure
has been increasing for several years. More people than ever are in work
principally because increasing numbers of women have entered the
employment sector in part-time work.
The 25% classified as ‘economically inactive’ amounted to 7.93 million
people in 2004, which is an increase of 200,000 in three years. Of this group,
just over 2 million said they wanted a job, although they were not actively
looking for one. Many of this group are not actively seeking work because
they are students, long-term sick, or looking after a family at home.
The number of unemployed is the lowest it has been for 20 years. However,
recent government programmes have increased the number of hidden
unemployed, which means that the overall number of people in the age range
16 to 65 who do not have a job in the UK continues to increase. Therefore the
number of people who suffer poverty through not having employment
continues to increase.
ILO-defined unemployment in August 2005 was 1.42 million (4.7%), up by
21,000 from the previous year. Unemployment also shows an increase from
previous years. In 1998 the unemployment rate was 4.6% and this fell to 3.1%
in 2002. Since then it has risen to the current le vel of 4.7%.
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Causes of unemployment
Unemployment can be caused in a number of ways. There are large -scale
economic and political reasons that affect society in general and there are
personal reasons that affect the individual.
• Economic reasons
– Structural change
– Technological change
– Government policy
– Foreign competition
– World trade cycle
• Individual reasons
– Education and lifestyle
Structural change
Structural changes occur when sections of the economy become less
important and jobs are lost. Although other sections of the economy expand
and work is created, those who lose their jobs are often of an age and skill
level which makes it hard for them to gain alternative employment.
The structure of the economy is continuously changi ng and has done so for
many centuries. In the 1970s, manufacturing and mining accounting for 35%
of all jobs. However, the trend is away from manufacturing towards the
services sector. Between 1995 and 2000, employment levels in agriculture,
forestry and fishing and manufacturing fell steadily whereas the service
sector experienced an increase. In 2000 alone, about 100,000 jobs were lost in
UK manufacturing industry. Currently the BBC has three times as many
workers as the entire UK coal industry.
Technological change
As technology develops it alters demand and has an impact upon the way
work is done. For example, banks close branches and replace counter staff
with cash dispensers, telephone banking and on -line banking. Many skilled
jobs have been replaced by computers that diagnose problems and instruct
semi-skilled workers on a step-by-step basis how to replace one component
with another. Products that were once commonplace have been replaced by
alternatives which require different skills to manufacture. For example,
cassette recorders were replaced by CD players then MP3 players. The VCR
is disappearing in the wake of the DVD. Therefore technological change can
create unemployment and deskilling, which leads to lower incomes and hence
poverty.
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CAUSES OF INEQUALITIES IN WEALTH
Government policy
Government policies can affect the level of economic activity in the country,
which affects the availability of employment, which in turn influences
poverty levels.
If the government raises more in tax than it spends, then it takes money out of
the economy and reduces economic activity. If it spends more tax than it
raises, i.e. it borrows, it puts more money into the economy and increases
economic activity.
If the government taxes businesses highly it can reduce their profitability and
encourage them to move abroad, taking jobs with them. If it taxes people
highly it reduces what they have to spend and this reduces economic activity.
If it taxes rich people and redistributes the wealth to poorer people, then it
may discourage the wealthy from working and investing, and reduce the
purchases of high-value products. At the same time it increases demand for
basic items and low-value products. Alternatively it may redistribute wealth
towards the wealthy by putting the tax burden on the poor and reducing
benefits for the very poor. This will encourage the wealthy to spend on high value commodities, reduce spending on low -value products and create a
disincentive for the poor to find work.
Government spending creates wealth in certain sectors of the econom y. Most
armament manufacturers would go out of business in the UK if it was not for
the government’s defence budget. When the Scottish Executive decided to
upgrade the M74 across Glasgow’s south side at a cost of £500 million, it
generated jobs in motorway construction in the region, and possibly
encouraged a ripple of increased economic activity throughout the area. By
refusing to upgrade the A9 to a dual carriageway at a cost of £600 million,
the same Executive denied the creation of road construction job s in the
Highlands, and the region also lost the boost to tourism and industry that this
new road would bring. Therefore government decisions have a big impact on
the levels of employment and unemployment in the economy in general, and
to individual regions and localities.
Foreign competition
Unemployment can be created when foreign countries manufacture products
that are more reliable and cheaper than those made in the UK. Shipbuilding
once employed hundreds of thousands of workers in the UK, and a signi ficant
proportion of the world’s ships were built in the UK. However, competition
from shipbuilding yards, particularly in South Korea where ships were built
faster and cheaper using more state -of-the-art equipment and lower-paid
workers, destroyed the UK industry. This meant that tens of thousands of jobs
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were lost. Foreign competition destroyed many manufacturing industries in
the UK – textiles, motor vehicle manufacture, electronic and electrical goods,
white goods, etc.
World trade cycle
The world economy regularly goes through periods of boom, when economic
activity increases and more work is available, and periods of recession, when
economic activity is reduced and unemployment increases. Currently the
world is emerging from a recession which start ed in the Far East and has been
helped along by the attack on the World Trade Centre and the uncertainty in
the price of oil caused by US invasions of Afghanistan and Iraq. The USA is
the world’s single biggest economy and the US government is currently
running up huge debts because it is spending more than it is raising in taxes.
This will have to end at some stage and that could force the US economy into
a recession, which could force the world into a further recession.
Education and lifestyle
Some reasons for unemployment are specific to the individual: for example,
the level of a person’s education will affect their employability.
Levels of unemployment by education, 2003
Level of education
Unemployment rate
Degree
2.7%
No qualifications
9.1%
Source: Adapted from ONS
The table above shows that unemployment rates are directly related to levels
of education, with a person with no qualifications being on average 3 times
more likely to be unemployed than some with a higher degree.
A person’s lifestyle can also have a major impact on their employability. A
person who abuses alcohol or misuses drugs can lose their employment
through taking too much time off or being unable to perform at an acceptable
level. Also the impact on health may make an individua l unemployable.
Another problem is obesity. Scotland is second only to the USA in obesity:
22% of men and 23% of women were classified as clinically obese in 2002,
while 43% of men and 34% of women were overweight. This means that over
half of all adults weigh more than their recommended weight. Obesity can
lead to a variety of health problems, including high blood pressure, coronary
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heart disease, osteoarthritis and diabetes. These can prevent people from
working. Estimates suggest that obesity costs t he country £7.4 billion per
year.
Activities
Make notes on:
• how unemployment is measured
• how the method of counting can have an impact of the level of
unemployment
• the current official methods used
• causes of unemployment.
Practice essay
‘Government policy has an important influence on levels of
unemployment in the UK but it is only one of many factors.’
Discuss.
(15 marks)
Low-income employment as a cause of poverty
Although being in a household where at least one person is in employment is
very important in reducing the risk of living in poverty, it does not eliminate
it. Working households now account for 40% of all those in poverty
(excluding pensioners), which is an increase from 30% in the late 1990s. This
shows that low-income poverty is on the increase in Scotland and throughout
the UK. Therefore low pay is a major contributory factor to poverty in the
UK and Scotland.
There is a big variation in earnings between the top 10% of earners in the UK
and the bottom 10%. The average gross weekly wage for those in full-time
work is just over £200 for a 40-hour week, whereas a person in the top 10%
of earners will gross nearly £800 per week – 4 times as much.
In 2005, the average hourly wage for those in the lowest 10% in part -time
work was £4.04. This is less than the National Minimum Wage.
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Factors that influence low-paid employment are:
• gender
• the sector of the economy
• geography.
Gender
The pay differentials between men and women exist across all occupations
and across all industries. The best-paid women earn around 20% less than the
best-paid men while the worst-paid women earn about 10% less than the
worst-paid men. Female median earnings are 13% less than male median
earnings. Average male hourly earnings for full -time workers are higher than
average female hourly earnings in all occupational groups. In other words,
gender pay inequalities are not just because women are more likely to work in
low-paid occupations.
However women are also more likely to work in low -paid employment than
men. In the UK in 2005, 7 million workers earned less than £6.50 per hour.
Over 4 million of them were women; 3 million were part -time workers, 80%
of whom were women.
(This subject is dealt with in more detail in the section on ‘Gender as a cause
of poverty’.)
The sector of the economy
Average female hourly earnings for full-time workers are less than £6.50 per
hour in four areas of occupation: elementary (routine occupations), personal
service (mainly health care and childcare services), sales and customer
service, and process, plant and machine operatives. Combined, these
occupations account for approximately 1 in 6 of full -time female workers.
Of all of those aged 25 or over who earn less than £6.50 per hour, 40% work
in the wholesale, retail, hotel and restaurant sectors. A further 25% are
directly employed by the public sector. Of workers aged 25 and over
employed in the wholesale, retail, hotel and restaurant sectors over 50% are
low paid, with two-thirds of these being women. Of those directly employed
by the public sector about 20% are low paid, with 80% of these being women.
Geography
In Scotland, the four areas with the highest proportion of low-paid workers
are the Scottish Borders, Moray, West Dunbartonshire, and Dumfries and
Galloway. These are mainly rural areas. The four areas with the lowest
number of low-paid workers are East Lothian, Aberdeen City, Edinburgh and
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CAUSES OF INEQUALITIES IN WEALTH
South Ayrshire. There are 50% more people earning low pay in the Scottish
Borders than in East Lothian.
The influence of geography on low income is related to the availability of
work in a given region and the type of work available there. In rural areas
there are fewer jobs available so employers are not competing for workers.
Therefore wage levels can be depressed. Also the work is often seasonal and
traditionally non-unionised, so wage rates are low. Hotel and tourist trade and
agricultural employment have traditionally been low -income industries, and
the main big employer, the local authority, has seen wages a nd conditions
reduced since the privatisation programme of the 1980s and 1990s.
Other factors linked to low pay that lead to poverty
People at the low-pay end of the labour market also face disproportionate job
insecurity. Research by the Joseph Rowntree Foundation shows that 40% of
those in low-paid employment are not in the same job six months later. They
form part of the ‘low pay, no pay’ cycle that has not improved over the past
decade. Job insecurity contributes to low self -esteem, stress and ill health,
which can prevent people from being able to secure and retain work.
Despite some improvement over the past 10 years in employment training for
those in low-paid employment, those with no qualifications are still 3 times
less likely to receive training compared with those with some qualifications.
Therefore they are more likely to remain in low -paid employment.
Another problem is that over 50% of employees who have incomes that are
below average do not contribute to a non-state pension. This means their lowincome status will continue into their retirement and will make sure that the
poverty they face during their working life also continues into their later
years. Low pay usually means for life.
Activities
Make notes on:
•
•
22
pay differentials in the UK
the factors that influence low-paid employment.
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CAUSES OF INEQUALITIES IN WEALTH
Gender as a cause of poverty
There have been significant changes in the social and economic position of
women in UK society in the past 50 years.
Socially, women have retained their traditional role of carer for home,
children, the elderly and disabled. However, there has been a decline in the
number of people getting married, a trend towards later marriage, while
divorce and separation are on the increase. This has led to a significant
increase in the number of lone parents in the UK.
Women form the majority of lone parents and pensioners. These are two of
the poorest groups in the UK. Therefore women are more likely to be poor
than men are.
In 2003, 73% of working-age women were economically active in either fulltime or part-time work. Families are increasingly dependent on female
earnings.
Even after 30 years of legislation which has led to some improvement,
women’s average earnings are still 80% of men’s average earnings.
Women are more likely to suffer from poverty for a variety of reasons:
•
•
•
•
•
•
•
women generally have lower wage levels (see previous section)
there is a ‘glass ceiling’ preventing women reaching top levels of jobs
most lone parents are women
women have a greater burden in bearing the cost of children
women have a traditional role as carer
women are more dependent on welfare payments
women live longer.
Glass ceiling
The glass ceiling was a phrase coined in the 1980s to describe the fact that
women could not progress to the top levels in business and public life.
However, over the past 25 years, there have been significant improvements in
the promotion prospects of women, especially since the late 1990s. Despite
this, women are still badly under-represented at the top levels of management
and decision-making in the UK.
Women are concentrated in particular occupations in the UK labour market.
Women account for 79% of administrative and secretarial workers and 83%
of workers providing personal services. These tend to be the lower-paid
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CAUSES OF INEQUALITIES IN WEALTH
sectors of the economy. In those sectors where the employment provides
higher levels of income, such as those with a skilled trade or managers and
senior officials, women comprise only 9% and 31% respectively.
Women are 52% of the adult UK population but they are represented in small
numbers in the very top positions in British society. In 2004 a Guardian
investigation of the top 100 companies found that only 114 out of 1,400
boardroom seats were occupied by women and only 17 were full -time
executives. Among the top 350 firms only 3% of executive directors were
women.
The Equal Opportunities Commission found women were hugely under represented in positions of influence in business, the police, the media and
the judiciary. Just 9% of top business leaders and national newspaper editors
were women, 7% of the senior judiciary and senior police ranks, and 1% of
senior army personnel.
Research has shown that the two main reasons for this are the role that
women are expected to play in society, and discrimination by the male dominated decision-makers.
Women’s career options narrow when they have children, with 20% facing a
cut in pay or dismissal when they become pregnant, and many take jobs ‘well
below’ their abilities. One in five women ha ve turned down a job because of
their role as an unpaid carer or parent.
However, recently there have been significant improvements for women.
These have not yet created a level playing field for women and their
promotion prospects, but they have made women’s position much healthier.
At every tier of management – except at the top of the largest corporations –
women have made huge inroads since the late 1990s. In 2005, the number of
women directors increased from less than 1 in 10 to 1 in 7. Women made up
38% of team leaders, compared with 26% in 2000. Overall, women formed
3% of British management whereas they comprised 2% in 2000 and less than
2% in 1975.
In the mid 1980s, only 5% of MPs were women, compared with 18% today.
Women also now hold chief executive posts in 29% of National Health
Service bodies and 25% of top management posts in the Civil Service.
Lone parents
Between 1971 and 2004, the number of lone -parent households with
dependent children increased and the number of children living in one -parent
families increased significantly. In the 1970s, 6% of children lived in single -
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CAUSES OF INEQUALITIES IN WEALTH
parent families headed by their mother and 1% lived with their single -parent
father. In 2004, 21% of dependent children lived in single -parent families
headed by their mother and 2% of children lived with their father alone.
Therefore there has been a threefold increase in the number of dependent
children living with a single parent.
There are more than 280,000 children living in just over 162,000 one -parent
families in Scotland.
Just under 10% of households in England and Wales are lone -parent families
and over 90% of these are headed by a woman. In 2004 20% of children in
Britain lived in a one-parent family, a rise from 12% in 1981. Britain now has
the largest proportion of children living in single-parent families in the
European Union. In Belgium and Germany the figure is 14%, in France 13%,
with the percentages decreasing down to 6% in Spain.
Male lone parents are more likely (63%) to be in work than women (48%).
They are also more likely to be in full-time work than women, who mainly
work part-time. Overall, more than half of women lone -parent households
with dependent children have no work, 26% cent part -time and 21% full-time.
Lack of affordable, high-quality child care is one of the key reasons for
relatively low employment rates. Lone parents’ chances of finding and
keeping jobs are much greater if they have children above five, have one or
two children, are over 35 years, are owner occupiers, are divorced, have
educational qualifications and receive maintenance.
The cost of bringing up children as a single parent means that many single
mothers live in poverty. Single mothers have to live on benefits, find the cost
of child minders or find employment that ca n fit around their care
commitments, so most single mothers find themselves living at or below the
poverty line.
One-parent families are one of the groups most vulnerable to poverty. In
1999, 70% of single parent households in Scotland had a net annual income
of less than £10,000, compared with 25% of small two -parent families. 79%
of single parents having no savings, compared with 41% of two parent
families. With the majority of single parents lacking income it affects their
standards of living (see the table on the next page).
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CAUSES OF INEQUALITIES IN WEALTH
Table: Ownership of selected items
Item
Single-parent families
Two-parent families
Car
33%
86%
Telephone
88%
98%
Computer
24%
54%
Internet Access
6%
26%
Source: Scottish Household Survey 2000
Children in one-parent families are much more likely to go without
necessities than children in two-parent families, whether or not their parents
are in work. However, lone parents spend almost as much on their children as
married parents by spending considerably less on themselves, in cluding
frequently going without food.
Single-parent households in Scotland are much more dependent on rented
housing and are more likely to live in a flat than two -parent families are. In
1999 only 25% of single parents lived in owner occupied housing, compared
with 71% of two-parent families. Single parents also tend to move more often
than two-parent families, with 41% having lived in their present home for 2
years or less, compared to 24% of two-parent families.
Women as carers
As a consequence of their caring role, many women are unable to maintain
uninterrupted employment throughout their working lives and therefore do
not have adequate pension entitlement. Therefore many women experience
poverty because they look after children, are single parents, have low paid
and unpromoted work. Many do not get occupational pensions, or cannot
afford private pensions, and continue to live in poverty in their retirement.
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Activities
Make notes on why women are more likely to suffer from poverty:
•
•
•
•
social reasons
the glass ceiling
impact of lone parenthood
cost of bringing up children and role as carer.
Practice essay
Critically assess the view that gender -based poverty is a product of
society’s expectations.
(15 marks)
Age as a cause of poverty
Two groups vulnerable to poverty are the young and the elderly. Over recent
years, government policies have reduced the levels of poverty in both of these
groups. However, both still form significant groups living in poverty.
Child poverty
In 1997, between 3 to 4 million children, 30% of children in the UK, lived in
poverty. This was 3 times the proportion in poverty in 1979. Between 1997
and 2004 government policies led to 1.3 million fewer children being in
poverty than would otherwise have been the case: a fall of over 25%.
However, in 2005, 25% of children lived in poverty. In some regions, child
poverty is even higher, rising to 54% in inner London. The worst levels of
deprivation are to be found in small areas in our towns and in rural
communities. In some wards over 90% of children live in poverty.
Poverty affects every area of a child’s development – social, educational and
personal. 33% of children in poverty go without the meals, or toys, or the
clothes that they need.
Living on a low income means that children’s diet and health can suffer.
Poorer children are more likely to live in sub -standard housing, in areas with
few shops or amenities and where they have little or no space to play safely.
Children from the bottom social class are 4 times more likely to die in an
accident and have nearly twice the rate of long-standing illness than those
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CAUSES OF INEQUALITIES IN WEALTH
living in households with high incomes. They are also more likely to be
smaller at birth and shorter in height.
Children who grow up in poverty are less likely to do well at school and have
poorer school attendance records.
There are also long-term effects of being brought up in poverty. As adults
they are more likely to suffer ill health, be unemployed or homeless. They are
more likely to become involved in offending and drug or alcohol abuse. They
are more likely to become involved in abusive relationships.
Once in poverty, children often stay in poverty well into adult life. Recent
research has found that most people remain in the same income level as their
parents. Research has also shown that the opportunities to break out of the
poverty cycle have reduced. The chance of being better off than their parents
has reduced for people who grew up in the 1980s and 1990s, compared with
people who grew up in the 1960s and 1970s.
Key factors that prevent children from breaking free of the poverty cycle
include missing periods of school, being in care, being known to the police,
misusing drugs, teenage parenthood, and being out of education, employment
or training between the ages of 16 and 18.
There are 600,000 children under the age of three living in poverty and there
are only 42,740 free or subsidised childcare places for disadvantaged
families. The availability of good-quality child care is crucial. It enables
parents to work or train for jobs, and gives children a head start in life. Early years care and education is known to improve children’s future educational
achievement and health, but almost all child -care services for children under
three are private, and only those parents in well-paid employment can afford
them.
Pensioner poverty
Pensioner poverty fell by 250,000 between 2000/1 and 2003/4; however,
more than 2 million still live below the poverty line. In 2005, the state
pension was just £82.05 a week for a single person and £131.20 for a
couple. Research by the Family Budget Unit revealed that a single pensioner
needs up to £125 a week to pay for basic requirements like a healthy diet,
adequate heating and transport.
For most pensioners in the UK the state pension is the single most important
source of income. If it is inadequate then they will suffer from poverty.
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In 1980 the link between state pensions and earnings was abolished. As a
result, the value of the basic state pension compared with average earnings is
falling. The falling value of the state pension means that increasing numbers
of pensioners face relative poverty.
For some, the falling value of the state pension was made up by a pension
from a company pension scheme into which they had paid when they were
employed. However, through the late 1990s and into the early twenty -first
century, employers increasingly closed these pension schemes down,
switched from final-salary pension schemes to money purchase schemes and
cut their employer contributions. Thus for both new employees and many
existing employees, the level of their final pension could no longer be
guaranteed.
Pensioners who live in poverty do so for a variety of reasons. Many never
escape the cycle of poverty into which they were born. Children born into
poor families often struggle in the education system and reach retirement age
with a much lower pension entitlement and very few savings.
70% of women have no private pension of their own, and because they live
longer than men, they face a longer period of poverty and ill health.
Activities
Make notes on:
• the extent of poverty among children
• the impact of poverty on children’s health, education and life
chances
• child care provision
• the extent of poverty among the elderly
• reasons for poverty among the elderly
• reasons for gender poverty among the elderly
• reasons for uncertainty in pension levels in the future.
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CAUSES OF INEQUALITIES IN WEALTH
Race as a cause of poverty
Risk of being on low income based on ethnic
characteristics 2002/03 (60% below median
income after housing costs)
White
20%
Asian
45%
Indian
22%
Pakistani/Bangladeshi
69%
Source: DWP – HBAI – 2002/03
All ethnic groups are more likely to be on lower incomes compared with
whites. However, there are significant differe nces among the ethnic
communities both in levels of poverty and reasons for poverty. For example,
Indian poverty levels are very close to those of whites whereas the Pakistani
and Bangladeshi communities suffer 3 to 4 times white poverty levels.
Pakistanis and Bangladeshis are the poorest racial group in the UK. This
poverty is caused by high unemployment among men; low levels of economic
activity among women; low pay; and large family sizes. The social security
system, especially means-tested benefits, contribute a large proportion of the
incomes of Pakistanis and Bangladeshis.
Indians have high levels of employment, and their earnings are on a par with
those of white workers. Although overall their rates of poverty are higher
than for white households, these groups are prospering.
Many people of Caribbean origin suffer higher -than-average rates of
unemployment, and there is a high rate of lone parenthood in this community.
Wages for Caribbean men (though not for women) also tend to fall below
those of their white equivalents. Africans’ incomes are lower than those of
Caribbeans.
There are various reasons for high levels of unemployment and low incomes
in the ethnic minority communities.
Education
Pakistanis, blacks and Bangladeshis have significantly l ower education
attainment than whites, at all levels, but Indians and Chinese have higher
levels of educational attainment.
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Indian pupils are more likely to get qualifications than other ethnic groups:
66% of Indian girls and 54% of Indian boys got five or more GCSEs in 1999.
This contrasts with only 37% of Pakistani and Bangladeshi girls and 22% of
Pakistani and Bangladeshi boys. The average for whites was 51%.
Housing, transport and access to work
The proportion of whites and Indians living in unfit h ousing is the same.
However, Pakistani and Bangladeshis are three times more likely to live in
substandard housing. Pakistanis, Bangladeshis and Black Caribbeans are
more likely to live in areas of multiple deprivation in inner city areas.
Industry is less likely to be attracted to these areas.
Industry often moves to areas on the periphery of towns where car access is
required. These ethnic minority groups are more likely to use public
transport, and are not as able to commute so far. Pakistanis and Bang ladeshis
followed by Black Caribbeans are twice as likely to be dependant on public
transport as Whites and therefore are not able to commute to get work.
Therefore there are fewer job opportunities available to them.
Health: Indians and Chinese have the same levels of self-reported health
problems as whites whereas Pakistanis and Bangladeshis report 50% more
health problems and Black Caribbeans report 33% more. Therefore the latter
groups are more likely to be off work and lose income and jobs through il l
health.
Fluency in the English language has an effect on all groups particularly the
first generation of ethnic minority immigrants.
Discrimination: discrimination continues to harm ethnic minorities. Surveys
have shown that ethnic minorities with the same CVs, applying for the same
jobs, were called for interview less frequently. Employment tribunals have
frequently found evidence of race discrimination. Finally Public Attitude
Surveys suggest ethnic minorities and the wider public believe race
discrimination continues to exist in employment.
In 2000, the average net weekly pay for a white male was £295, while the
average weekly pay for a Pakistani male was £40 per week less. An average
Bangladeshi male wage was only £140. However, the average weekly income
for an Indian man was £15 greater than for a white male.
Indian wage levels are close to or better than White wage levels; however,
Pakistani and Bangladeshi wage levels are considerably less than White wage
levels. Pakistani and Bangladeshi males are overrepresented in jobs where
there is low pay and there is little chance of promotion whereas Indians have
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CAUSES OF INEQUALITIES IN WEALTH
a significant presence in highly-paid jobs with good prospects. 52% of male
Bangladeshis are employed in the restaurant industry compared to o nly 1% of
whites.
Activities
Make notes on:
•
•
•
variations in the risk of poverty by ethnic group in the UK
the reasons for poverty among ethnic groups
differentials in average wage by ethnic group.
Practice essay
To what extent do ethnic groups face inequalities in wealth?
(15 marks)
Geography and poverty
Levels of poverty are not equally distributed across the UK. There is a north –
south divide with average levels of poverty higher in northern areas. This
divide can be measured in several ways such as looking at income levels,
unemployment levels, house prices and health. However, within every region
there are areas of wealth and poverty existing side by side.
Some argue that a north–south divide does not exist because there are pockets
of poverty and wealth in all parts of the UK. For example, London is the
richest part of the UK but has six of the poorest boroughs in the UK. Glasgow
is one of the UK’s poorest areas yet has many areas of wealth.
However, those who argue that a divide exists point to the fact that most
areas with above-average levels of unemployment are in the north and most
areas with higher disposable incomes are in the south. Also more people live
on benefits in the north, while London and the south -east have the strongest
economies. The north suffers from greater ill health than the south while
house prices are much higher in the south.
In 2004, the UK average level of unemployment was 4.9%, whereas in
Scotland it was 5.2%, in the north of England it was 5.9%, while in the south-
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east it was only 3.7%. These differences were reflected in income
differentials. Disposable income per head in Scotland was 3% below the
national average and in the north-east of England it was 12% below, whereas
London was 20% higher than the national average.
Those parliamentary constituencies with worse -than-average health statistics
were in Scotland and in northern England whereas those with the best
averages were in the south of England. For example, Glasgow City had the
lowest male life expectancy of 69.1 years, whereas in Kensington and
Chelsea men can expect to live until they are 79.8: a difference of over 10
years. The 10 areas with the longest life expectancy for both men and women
are in London and the south.
There is a clear north–south divide in house prices. With the exception of east
England all regions to the south of the line between the Wash to the Bristol
Channel have average house prices well above the national average. All
regions to the north of this line have average house p rices that are well below
this average.
However, within regions there are clear differences in the wealth and poverty
in different communities. The new Scottish Index of Multiple Deprivation
(SIMD) divides the country into 6,500 ‘data zones’. A map of po verty and
deprivation shows that the worst areas are parts of west central Scotland –
Glasgow City, West Dunbartonshire and Inverclyde – along with Dundee.
Glasgow is worst in 8 out of 14 deprivation indicators such as low -income
households, poor health, drug abuse, overcrowding and premature death.
However, these problems are not evenly distributed across Glasgow city, with
parts of Shettleston suffering some of the worst deprivation in the UK
whereas other parts of the city are amongst the most affluent in the country.
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CAUSES OF INEQUALITIES IN WEALTH
Table: Health and wealth inequalities in two parliamentary areas of
Scotland
Category
Rich area
Poor area
£31,478
£17,170
8%
34%
£111,057
£39,539
Owner-occupiers
74%
36%
Household – no car
31%
68%
Life expectancy: male
76.5
63.9
Life expectancy: female
81.6
75.9
Long-term limiting illness
16%
32%
7%
28%
15%
35%
Wealth and income
Average gross income
Income-support claimants
Average house price
Health and lifestyle
Adults unable to work due to disability
Lone-parent households
Source: adapted from Public Health Institute of Scotland website (most figures have
been rounded)
Activities
Make notes on:
•
regional differentials in poverty.
Practice essay
‘The north–south divide in wealth does not exist.’ Discuss.
(15 marks)
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Section 4
Inequalities in health
Health is influenced by a number of factors:
•
•
•
•
Age
Ethnicity
Gender
Socio-economic status and lifestyle
Age
The 2001 census showed that 91% of people in England and Wales reported
good/fairly good health. However, as expected, there was an increase in ill
health (a steeper health gradient) as people grew older. 99% of children aged
under 16 had good or fairly good health. The least healthy group were those
aged 75 and over, with only 72% indicating t hey were in good/fairly good
health. For those reporting good health the figures ranged from 90% for
children under 16 to only 28% for those over 75.
As people get older they are more likely to experience a longstanding illness
or disability, including one that limits their daily activities or work in some
way. Long-term disability or illness was lowest in children aged under 5 at
only 3%, rising to around 40% for men and women aged 45 to 64, and to over
60% for those aged 75 and over. For those aged 90 an d over it peaks at 75%.
(Note. Although related, the census questions on general health and limiting
long-term illness or disability measure different aspects of health. Only 43%
who reported limiting long-term illness or disability also said their healt h was
not good. This may explain some of the apparent inconsistencies in the
statistics.)
As people get older their health deteriorates partly due to the accumulation of
problems caused by lifestyle choices earlier in life such as smoking,
excessive sport or staying in fashion, sometimes as a consequence of the type
of work they did, but ultimately through the ageing process itself. The body
simply wears out and cannot repair itself as efficiently as it once did. Older
people are more likely to be involved in accidents because their senses such
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as balance and eyesight are not as acute as they were in the past. As a result,
old people put more pressure on health services.
In 2002, 25% of those aged 75 and over attended the casualty or out -patient
departments of a hospital, compared with 14% of people of all ages. In the
same year, the average hospital stay for the general population was 7 nights.
However, for those aged 75 and over the average length of stay was almost
double at 12 nights.
In 2002, 19% of all accidents in the home involved people aged 65 and over
and 39.7% of pedestrian deaths were people aged 60 and over.
Elderly people have particular problems that society in general does not face
to the same extent. The Alzheimer’s Society estimates t hat there over 750,000
people in the UK with dementia, of whom only 18,000 are aged under 65.
Therefore 98% of the victims of this condition are over 65.
Hypothermia is another problem for the elderly. In 2002, although only 71
people aged 65 and over had hypothermia as the underlying cause recorded on
their death certificates, during the winter of 2003/2004, 21,500 people over
the age of 65 died as a result of the cold in England and Wales alone. This is
based on the calculations for ‘winter mortality’ wh ich measures the increased
mortality rates through the winter months.
Activities
Make notes on:
•
•
the health gradient in the UK
the reasons for failing health in older people.
Ethnicity
Bangladeshi and Pakistani men and women are 3 –4 times more likely than the
general population to rate their health as bad or very bad. Indians are also
more likely than the general population to rate their health as bad.
Black Caribbean women are the only other minority ethnic group who are
significantly more likely than the general population to describe their health
as bad or very bad.
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Different minority ethnic groups vary in their likelihood of having specific
diseases. Pakistanis and Bangladeshis of both sexes were more than 5 times
as likely as the general population to have diabetes, and Indian men and
women were almost 3 times as likely. Black Caribbeans were also more likely
than the general population to suffer from diabetes, particularly Black
Caribbean women. Rates of diabetes among the Chinese were n ot
significantly different from the general population.
Pakistani and Bangladeshi men had rates of cardiovascular disease (CVD)
about 60% to 70% higher than men in the general population, while Chinese
men had lower rates. The picture was similar for wome n, with Chinese
women having lower rates of CVD conditions than women in general, while
Pakistani and Bangladeshi women had higher rates. The rate of CVD
conditions was also higher among Black Caribbean women.
The only breakdown available for infant morta lity rates within the ethnic
minorities relates to mother’s country of birth, which may not give an
accurate picture of rates within UK groups in general. In 2002, the death rate
for infants within 3 months of birth and still births were:
•
•
•
•
•
7.8 for mothers born in the United Kingdom
10.5 for mothers born in Bangladesh
10.6 for mothers born in India
14.5 for mothers born in Pakistan
15.4 for mothers born in the Caribbean.
The 1999 Health Survey for England found that smoking was more common
among certain ethnic groups: 27% of men in the general population reported
being smokers compared with 44% of Bangladeshi men and 35% of Black
Caribbean men. Indian (23%), Pakistani (26%) and Chinese (17%) men were
less likely to report being smokers.
However, women in the ethnic minority groups were less likely to smoke than
women in the general population: 27% of women in the general population
reported being smokers compared with 25% of Black Caribbean women, 9%
of Chinese women, 6% of Indian women, 5% of P akistani women and 1% of
Bangladeshi women. Also among children aged 8 –15, Indian, Pakistani,
Bangladeshi and Chinese children were less likely to report ever having
smoked compared with the general population. In the general population, 19%
of boys and 21% of girls reported having smoked a cigarette.
The survey also found that Bangladeshis (both men and women) were more
likely than other groups to report chewing tobacco: 19% of Bangladeshi men
and 26% of Bangladeshi women reported chewing tobacco compare d with 2%
and 6% for Indian/Pakistani men and women, respectively.
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INEQUALITIES IN HEALTH
Table: Alcohol consumption
Non-drinkers
Men
General population
Consumed more than govt.
recommended limit
Women
Men
Women
(3/4 units)
(2/3 units)
7%
12%
46%
29%
Indian
33%
64%
n/a
5%
Bangladeshi
96%
99%
n/a
n/a
Pakistani
91%
97%
n/a
1%
Black Caribbean
13%
18%
n/a
n/a
Chinese
30%
41%
n/a
17%
Source: Adapted from 1999 Health Survey for England
All ethnic minority groups were less likely to drink alcohol than the general
population and consumed smaller amounts.
Among 8- to 15-year-olds, 40% of boys and 32% of girls in the general
population reported drinking alcohol. Indian and Chinese children were much
less likely to report ever having drunk alcohol, and reported rates of alcoho l
use were particularly low among Pakistani and Bangladeshi children.
Socio-economic disadvantage is an important determinant of health within
minority ethnic groups just as it is for the population as a whole. Indians,
African Asians and Chinese, who are closest to whites in income, are as
healthy as whites, whereas Pakistanis, Bangladeshis and Caribbeans have the
poorest health of anyone in Britain. These are the three poorest ethnic groups
in Britain. Pakistanis and Bangladeshis are 50% more likely to s uffer ill
health than whites, and Caribbeans are 30% more likely to be in poor health.
Factors such as racial harassment and discrimination also have an impact on
the health of ethnic minority people. Violence which is verbal and sustained
can have an impact on the mental well-being of the victims. When linked to
physical abuse this has both a physical and a psychological impact on health.
Even the fear of going out can have an impact through lack of exercise. Those
who had been verbally harassed reported a 60% higher rate of fair or poor
health, while those who reported racially motivated damage to their property
or physical attacks reported fair or poor health at double the rate.
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Finally, gender combined with ethnicity and socio -economic position has an
additional impact. Research suggests that culturally determined domestic
responsibilities influence women’s health. Caring responsibilities are a risk
factor for women in all ethnic groups but a significant additional risk factor
for ethnic minority women who have four or more children.
Activities
Make notes on:
• the variations in health by ethnic group
• the reasons for the health variations by ethnic group
• biology
• lifestyle – culture/religion
• income
• impact of racism and discrimination.
Practice essay
To what extent is socio-economic status the main contributory factor in
ill health among ethnic minority groups?
(15 marks)
Gender
Biological differences between women and men affect their need for health
care. There are obvious differences such as women’s reproductive ability that
give them ‘special needs’ relating to fertility control, pregnancy and
childbirth. However, the biological differences lead to variations in genetics,
hormones and metabolism which affect male and female patterns of heart
disease and infections.
Although the UK statistics show significant differences between women and
men in health status, these differences are influenced by differences in
income and social class, age and ethnicity.
Health is also influenced by social differences: differences in the living and
working conditions of women and men, and in their access to a wide range of
resources, lead to different levels of risk of developing some health problems.
Gender also influences the attitudes of women and men towards using health
care.
HEALTH AND WEALTH INEQUALITIES IN THE UK (MODERN STUDIES, H)
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INEQUALITIES IN HEALTH
A widely used indicator of health is life expectancy. Life expectancy at birth
for males and females born in the United Kingdom has continued to rise.
Between 1971 and 2003 it increased from 69.1 to 76.2 years for males an d
from 75.3 to 80.5 years for females. While female life expectancy at birth has
been consistently higher than that of males throughout this period, the gap
has been narrowing, from 6.2 years in 1971 to 4.3 years in 2001.
Differences in life expectancy reflect biological and social differences. Men
are more likely than women to die prematurely from heart disease and have
higher death rates from lung cancer, injuries, poisoning and suicide. Women
are slightly more likely than men to report that they have re cently
experienced ill health. Compared with men in the same social class, women in
the UK have a longer life expectancy.
In 1981 the expected time lived in poor health for males was 6.4 years. By
2001 this had risen to 8.7 years. Between 1981 and 2001 th e number of years
females could expect to live in poor health increased from 10.1 to 11.6 years.
Women are slightly more likely than men to be admitted to hospital and they
also make more use of GP services than men, but the gender gap is small.
Women and men also differ in their patterns of health -related behaviour. For
example, men have traditionally smoked more cigarettes and consumed more
alcohol than women.
Recent studies have shown that biology affects health in ways other than
reproduction. Genetics and hormones being different in men and women have
an impact on medical conditions. For example, men tend to develop heart
disease ten years earlier than women. Women’s immune systems make them
more resistant than men to some kinds of infection including tuberculosis,
whereas women are 2.5 times more likely than men to develop diabetes.
Gender differences in living and working conditions lead to inequalities in
health between men and women. Research has shown that women’s
traditional domestic responsibilities lead to higher levels of depression. This
is particularly true for women raising their families in poverty. Women are 2 –
3 times more likely than men to be affected by depression or anxiety.
Men’s traditional role as breadwinner means they are more likely to die
prematurely from occupational disease and injuries – particularly those men
living in poverty. Men are also more likely than women to be pressured by
society to become involved in dangerous activities such as smoking,
excessive drinking and dangerous driving. In 2001, male deaths as a result of
road accidents were nearly 3 times the number for women, and more men die
from lung cancer due to higher rates of smoking, as well as cancer of the
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INEQUALITIES IN HEALTH
stomach and colon. The number of male deaths from ch ronic liver disease and
cirrhosis was nearly twice the number of female deaths.
Although men are more likely than women to die of injuries, women are more
likely to die of injuries sustained at home.
There are important differences in causes of death be tween women and men.
Across the UK, the major killers for both groups are cancer and circulatory
diseases. However, although the death rates from circulatory disease are
similar for women and men, females are more likely than males to die from
strokes associated with older age, while male deaths are higher for heart
attacks which occur earlier. This is reflected in differences in mortality
related to age. Females have higher death rates for those conditions
associated with increasing age.
Activities
Make notes on:
• the variations in health between men and women
• the reasons for gender differences in mortality (death rate) and
morbidity (likelihood of developing illness).
Practice essay
Critically examine the view that biology is the main factor in h ealth
differences between the genders.
(15 marks)
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INEQUALITIES IN HEALTH
Socio-economic status and lifestyle
An individual’s health is the product of several factors including genetics,
occupation, emotional state, diet, habits and exercise. Many of the reasons for
increased levels of mortality and morbidity in the lower socio -economic
classes stem from lower incomes, bad lifestyles, a poor physical living
environment and alienation from community and society that are the product
of lower income levels.
Social status by occupation has a significant impact on limiting long -term
health and disability. Partly because of the nature of the work, but mostly
because of the lifestyle afforded by the income from work, those in routine
employment have the worst self-reported ill health. In 2001, the number of
people in routine occupations who rated their heath as not good was more
than twice that of people in higher managerial and professional occupations.
However, those not in employment had the worst health record of all. Those
who were long-term unemployed were 3 times more likely to report suffering
from ill health than those in higher managerial and professional occupations.
The worst rate was for those who had never worked. Their rate was 6 times
the rate for those in managerial and professional occupations.
Figures show that mortality rates increase, the lower the social class. The
highest mortality rates occurred in social class V, and in the United Kingdom
as a whole these rates were 3 times higher than mortality in social c lass I.
This pattern is the same for each region of the United Kingdom, although the
differences vary between regions. For example, in Northern Ireland mortality
rates for people in social class V were 5 times greater than those in social
class I, whereas in south-east England mortality rates for people in social
class V were double those in social class I.
Class and stress
People in lower social classes suffer from stressful situations which they
cannot find ways to relieve. Continuous anxiety, insecurit y, low self-esteem,
social isolation and lack of control over work and home life have powerful
effects on health. Insecurity and low self -esteem can stem from being
unemployed or being in insecure low-paid work and being unable to provide
adequately for one’s family over long periods of time. Feelings of inadequacy
accumulate throughout life and increase the chances of poor mental health
and premature death.
Stress creates tension which has a physical effect on heart functions and the
immune system. If people feel tense too often or the tension goes on for too
long, they become more vulnerable to a wide range of conditions including
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infections, diabetes, high blood pressure, heart attack, stroke, depression and
aggression.
Class and accidents
The type of work a person does will also influence their chance of accidents.
A manual worker working in a dangerous environment will be at greater risk
from accident than a manager or an accountant. Coal miners suffer from
pneumonoconiosis (respiratory disease) bec ause of their occupation. The
environment where children are brought up also has an impact on accidents.
If children from lower social class areas live on or near busy roads, in an area
where there is no place for them to play safely, and in housing that i s in a
state of disrepair, then they are more likely to suffer accidents.
Mortality and morbidity rates
The infant mortality rate (IMR) is related to social circumstances. While
marriage is still the most common arrangement for children to be born into
there are significant variations between the more prosperous areas and the
more deprived areas. Twice as many children (40%) are born outside
marriage in East Inner London as in more prosperous areas.
Table: Percentage of live births and infant mortality ra te for different
regions and marriage status
Inside
marriage
England and Wales
• Percentage of live births
• Infant mortality (/1000
live births)
Prosperous areas
• Percentage of live births
• Infant mortality (/1000
live births)
East Inner London
• Percentage of live births
• Infant mortality (/1000
live births)
Outwith
marriage
joint
registration
Outwith
marriage
sole
registration
65.7
5.5
26.7
7.4
7.6
8.3
78.3
4.3
18.2
6.1
3.5
5.9
59.2
6.7
28.6
8.4
12.2
12.0
Source: Adapted from Office for National Statistics
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INEQUALITIES IN HEALTH
The infant mortality rate is significantly higher in those born into single parent families where there is sole registration. In East Inner London the IMR
is 50% higher than the national average in sole registration births an d double
the rate for the more prosperous areas.
Lifestyle has a clear impact on health in terms of the likelihood of becoming
infected with AIDS. The single largest cause is unprotected intercourse
between men and men and men and women.
Table: AIDS by probable route of infection 2002
United
Kingdom
Scotland
Sex
between
men
Injecting
drug use
Blood/
blood
products
Mother
to
infant
Other/
not
known
Total
1,285
Sex
between
men and
women
13,005
14,522
495
1,038
1,516
31,861
546
391
504
40
51
40
1,572
Sources: Adapted from Health Protection Agency Communicable Disease
Surveillance Centre; Institute of Child Health (London); Scottish Centre for
Infection and Environmental Health.
Table: Age-standardised mortality rates (per 100,000): by cause 2001
Ischaemic
heart
disease
Cerebro- Bronchitis
vascular and allied
disease
conditions
Cancer
Road
Suicides
traffic
and
accidents open
verdicts
All
other
causes
All
causes
United
Kingdom
192
103
44
251
6
10
175
954
Scotland
225
124
54
288
7
17
202
1,085
Sources: Adapted from Office for National Statistics; General Register Office for
Scotland
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Activities
Make notes on:
•
the impact of socio-economic status on:
– mortality rates
– morbidity rates
•
the reasons for these differences
•
the impact of lifestyle on health.
Practice essay
‘Socio-economic status and lifestyle have a significant impact on a
person’s health.’ Discuss.
(15 marks)
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HEALTH CASE AND SOCIAL WELFARE: THE POLITICAL DEBATE
Section 5
Health care and social welfare – the political debate
There has been an on-going political debate about the provision of social
welfare and health care in the UK since 1945.
In social welfare, individualists favour greater self -dependency. The
Conservative governments of the 1980s and 1990s believed that it was the
individual’s responsibility to seek employment to meet their needs and only
in exceptional circumstances should the state provide social welfare. Norman
Tebbit encapsulated this philosophy with his ‘on your bike’ soundbite.
This philosophy argued that welfare levels should be reduced to a point where
the unemployed would be forced to seek employment. The poor were divided
into the ‘deserving poor’ and the ‘undeserving poor’. Those who deserved
social welfare, the elderly and disabled for example, should be helped, but
groups such as unmarried mothers or young unemployed should be made to
be more responsible by reducing their levels of benefit.
The Labour Party opposed this philosophy and, when it was elected in 1997,
introduced a series of measures to help two groups in particular – children
and the elderly. However, they retained the philosophy of personal
responsibility in their ‘welfare to work’ programmes. The state collectively
would provide social welfare for those in need but it would ensure that
individuals would have to take responsibility to find ways into employment.
In health care, individualists favour greater private provision and greater
dependency on the individual to provide for their own health care. The
collectivists argue for more public provision based on taxation. Bot h sides
agree that current provision is inadequate to meet public demand.
The founders of the welfare state believed that, through collective public
provision, the health of the nation would improve to a point where the cost of
health care would start to fall. However, the cost of health care has continued
to escalate as people live longer, fall victim to more diseases and complex
diseases, and expect the NHS to provide an ever -increasing array of
expensive drugs and treatments to manage their chronic con ditions.
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Politically health care is a problem. The public want the best health care but
do not want to pay higher levels of tax. Yet politicians have to attempt to find
solutions. Through the 1980s and 1990s, Conservative governments attempted
to promote a more individualistic approach to the provision of health care by
promoting private treatment and insurance. They also tried to develop the
competition of the marketplace for health provision. This approach was
opposed by other political parties.
The Labour Party was elected in 1997, partly on the basis that the electors
wanted a more collectivist approach to health provision. Many were
concerned that their parents were being forced to use up much of their
inheritance on long-term health care and wanted better public provision.
The Labour government dismantled many of the market structures introduced
by the Conservatives. However, while they pursued a more collectivist
approach they overcame their traditional hostility towards private provision
and made increasing use of the private sector to try to contain the growing
waiting lists that reduced their political standing. They also extended their
use of Public–Private Partnerships for hospital building, which extend the
level of private work alongside NHS provision.
Meanwhile current Conservative philosophy has trimmed its individualist
approach.
The post-war debate between the collectivists and the individualists is set to
continue, with health and social welfare continuing to weave an erratic course
between the two.
In Sections 6 and 7, the mixture of collectivism and individualism as
developed by Labour governments since 1997 will be outlined.
Activities
Make notes on:
•
•
the collectivist approach to welfare provision
the individualist approach to welfare provision.
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POLICIES TO DEAL WITH WEALTH INEQUALITIES
Section 6
Policies to deal with wealth inequalities
The central theme of government social policy since 1997 is to promote
social inclusion in order to re-engage those in society who are poor and have
become detached from work, education, health and community. The
government has designed its social policy around getting the unemployed off
welfare and into work by making it easier to find pathways into work and
making it increasingly difficult or impossible for some groups to avoid the
programme.
It has increased the financial attraction of work by targeting its welfare
through tax credits for those in work and allowing benefits such as Job
Seekers Allowance to be time limited and by allowing benefits to fall as a
proportion of average incomes. Therefore there is an increased differential
between the incomes of those in work and those who are not, which is aimed
to increase the attraction of work.
In particular the government set a specific target to reduce child poverty. It
has targeted more support for families with dependent children, both through
tax credits and through other initiatives such as Sure Start.
Since 1997, successive Labour governments have sought to achieve their
goals through a variety of measures.
Measures taken to increase levels of employment:
• New Deal schemes for
– young people
– the long-term unemployed
– lone parents
– disabled people
• National Minimum Wage
• Working Tax Credit
• Child Tax Credit
• Skillseekers
• Modern Apprenticeships
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Measures taken to provide income for those not employed:
• Jobseeker’s Allowance
• Income Support changes targeted to children (replaced and enhanced by
Child Tax Credit and Working Tax Credit)
• Pension Credit (replaced and enhanced Minimum Income Guara ntee for
Pensioners)
• Winter Fuel Payments
• Changes to income tax and National Insurance contributions
Measures to increase levels of employment
New Deal schemes
The New Deal is the government’s main method of getting the unemployed
back into work or into training and skills improvement that will eventually
lead to work. Those who become unemployed and claim Job Seekers
Allowance or those who have not worked for other reasons are interviewed by
a New Deal personal advisor who draws up a planned route into employment.
This might include:
•
•
•
•
•
work experience with an employer or voluntary organisation
training that focuses on a specific job
courses to develop the skills that employers want
practical help with applying for jobs
interview technique practice.
Personal advisers are experts in the field of job hunting and have many
contacts in the workplace, especially on a local level. If, after undertaking
training or courses the individual has not found employment, the personal
adviser will continue to help them search for and get a job.
There are several New Deal schemes which were combined make up the New
Deal:
•
•
•
•
18–24 – Compulsory scheme for young people, launched April 1998
25 plus – Compulsory, launched June 1998
50 plus – Voluntary, aimed at older jobless, launched April 2000
Disabled People – Voluntary scheme, piloted from April 1999, to be
extended from July 2006
• Lone Parents – Voluntary, extended in April 2001
• Partners – Voluntary, to help partners of long-term jobless find work.
To encourage the unemployed back into work the government has also altered
the tax and benefit system to create an increasing differential in income
between those on benefits and those in work. This has reduced the proportion
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POLICIES TO DEAL WITH WEALTH INEQUALITIES
of children, in lone-parent families and in low-income families, who are
living in poverty and has increased the proportion of adults without children
who are in poverty.
The National Minimum Wage
The National Minimum Wage (NMW) was introduced to set a base level of
hourly income for low-paid workers in the UK. The NMW for an adult (22
and over) was £5.05 per hour in 2005, which is £202.00 before tax for a 40 hour week. The government’s aim is to encourage more workers to find jobs
because it has increased wage levels.
Working Tax Credit
Originally introduced as Working Families Tax Credit, this tax adjustment
was extended to all low-paid workers to encourage an increase in net income
to create a larger difference between these workers and those remaining on
benefits, aiming to end the ‘benefit-trap’. Working Tax Credit (WTC), allows
low-paid workers to retain more of their wages. By getting a tax credit they
pay less tax on their gross wage and therefore take home more income. The
NMW in combination with WTC has significantly increased the difference
between those in work and those remaining on benefits by choice.
The Working Tax Credit also has a childcare element. Families are eligible
for the childcare tax credit where a lone parent, or both partners in a couple,
work for at least 16 hours a week. It is worth up to 70% of eligible childcare
costs of up to £300 a week for a family with two or more children, or £175 a
week for a single-child family.
Child Tax Credit
Child Tax Credit is paid to families with children regard less of whether the
parents work. As eligibility is not linked to work, it is paid directly to the
carer. It is payable to couples with a combined income of up to £58,000,
although people whose income is close to the maximum will get very little.
In tax year 2005/2006, Child Tax Credit has two main parts:
• a family element of £545 per year, doubled in the financial year of a
child’s birth
• an amount per child of £1,690 per year.
All families with incomes of less than £50,000 a year will get at least £545 a
year from the ‘family element‘ of the credit. In addition, families with
incomes up to £13,910 a year should qualify for the ‘child element‘ of £1,690
a year for each child. This child element is then gradually withdrawn from
families with higher incomes.
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Skillseekers
Skillseekers is a training programme run by Local Enterprise Companies
(LECs) in Scotland. It encourages employers to train young people aged 16 –
24 towards a recognised workplace qualification by helping them with the
cost of training.
Most young people involved in Skillseekers are in employment, but there are
also training places for those having difficulty in finding a job.
All Skillseekers work towards nationally recognised Scottish or National
Vocational Qualifications (SVQs and NVQs), which are available for nearly
every kind of job. Each VQ is made up of units covering different aspects of
a particular job, and you can work through them at your own pace.
All 16 to 18 year olds are eligible for Skillseekers. The training pro vided is
flexible and dependent on individual ability, the level of qualification aimed
for and the needs of the employer.
(Based on information from Careers Scotland website:
http://www.careers-scotland.org.uk)
Modern Apprenticeships
Modern Apprenticeships were launched in Scotland in 1994. The aim was to
help address the perceived decline in the number of people holding
intermediate level vocational qualifications. They have the following main
characteristics:
• they are targeted at the 16–24 age group
• they provide work-based training leading to SVQ Level 3 or above
• training is based on employer-led frameworks, developed by the National
Training Organisations (NTOs) assisted in Scotland by the Enterprise
Networks (Scottish Enterprise, Scottish Executive, and Highlands and
Islands Enterprise (HIE)
• there is a ‘Core Skills’ element covering communication, numeracy,
problem solving, working with others, and information technology.
Modern Apprentices have employed status. In 2001, there were 17,000
Modern Apprentices in place in Scotland compared with 23,000 non -Modern
Apprenticeship Skillseekers. The number had risen from around 8,000 in
1998. The seven most popular ‘frameworks’ in Scotland are Construction,
Customer Services, Business Administration, Motor Vehicles, Engineering,
Electrotechnical and Hospitality.
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80% of firms acknowledged that involvement with Modern Apprenticeships
has encouraged them to recruit more young people or provide b etter training.
The main benefits of Modern Apprenticeships to businesses were found to be:
•
•
•
•
•
the development of a workforce with recognised qualifications
a better trained workforce
training taken more seriously by recruits
benefits in recruiting the right people
staff retention.
Activities
Make notes on the following measures taken to increase levels of
employment:
•
•
•
•
•
•
New Deals
National Minimum Wage
Working Tax Credit
Child Tax Credit
Skillseekers
Modern Apprenticeships.
Measures to provide income for those not employed
Jobseeker’s Allowance (JSA)
Jobseeker’s Allowance (JSA) is paid to unemployed people who are
participating in the New Deal, i.e. those who are:
• capable of working
• available for work
• actively seeking work.
To meet these requirements effectively a person must be actively engaged in
a New Deal scheme. A person who is unwilling or unable to participate in all
aspects of the New Deal scheme that they are on will have their JSA
withdrawn. It only lasts for 6 months by which time, under the conditions of
the New Deal, a person will be expected to have found employment or to
have moved on to education, training or disability. At this point JSA is
stopped.
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There are two types of JSA:
• contribution-based JSA
• income-based JSA
To qualify for contribution-based JSA a person must have paid or be treated
as having paid a certain number of national insurance (NI) contributions.
Contribution-based JSA is paid at a fixed rate based on age for up to 26
weeks.
Income-based JSA is for those who do not have sufficient NI contributions in
the preceding qualifying period. This would include those who have been
made redundant in a short period of time or young people who have never
worked. Income-based JSA is means-tested: those with savings over £8,000
do not qualify and savings over £3,000 affect how much income -based JSA
you can get.
Those aged 16 or 17 are unlikely to have worked for long enough since
reaching age 16 to pay enough NI contributions to get contribut ion-based
JSA. An unemployed 16 or 17 year old may be able to get income -based JSA
for a short period in special circumstances, for example if they are forced to
live away from their parents.
Income Support
Income Support is for people aged between 16 an d 60 who cannot normally
work (or who work less than 16 hours a week) and who are on a low income,
for example those who:
• are incapable of work because of illness or disability
• care for a sick or disabled person
• are a lone parent responsible for a child under 16.
Income Support is means tested and depends on circumstances. Regulations
approved by Parliament specify basic living expenses. This depends upon
age, family size, disabilities, etc. If the money coming in is less than this
amount, Income Support can make up the difference. Some income is ignored
such as Attendance Allowance and Disability Living Allowance and some
income is only taken partly into account, such as part -time earnings.
Those not normally be entitled to Income Support includ e:
• people working 16 hours or more a week
• people with a spouse or partner working 24 hours a week or more
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• people studying full-time (although there are exceptions for certain single
parents, certain disabled people, and certain students estrange d from their
parents)
• those with capital or savings over a certain level.
Because of the complicated rules it is not easy to work out Income Support
entitlements. Many people, including those with disabilities, do not claim the
Income Support that is due to them.
Other benefit entitlements for those in receipt of Income Support:
• Housing Benefit and Council Tax Benefit
• help with health costs, for example free prescriptions, free NHS dental
treatment, vouchers for glasses, and help with fares to h ospital for hospital
appointments
• grants and loans from the Social Fund
• free school meals.
Income Support is normally paid directly into a bank or building society
account.
Pension Credit
Pension Credit guarantees a minimum income for people of pe nsionable age.
In 2006, a single pensioner with an income under £114.05 per week will
receive a pension credit to make up the difference. For example, a pensioner
with a combined state pension and occupational pension of £90 will receive
pension credit of £24.05. For a pensioner couple the threshold is £174.05.
Those who have additional needs, such as caring responsibilities, or those
who are severely disabled or have particular housing costs may be entitled to
more.
Everyone aged over 75 gets a free TV licence.
Winter Fuel Payment
Winter Fuel Payment is paid to pensioners once yearly at the start of winter
to help meet the costs of keeping their homes warm. The rates vary depending
on age and other benefits claimed.
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Table: Winter Fuel Payment 2005–2006
Those who get
Pension Credit
Those who get no
Pension Credit
65–69
£200
£400
70–79
£250
£400
80+
£350
£500
Other income and savings do not affect Winter Fuel Payment. It is a one -off
payment.
Other benefits for those on low incomes paid by nation al government:
• no prescription charges
• free eye tests and spectacles
• free dental treatment.
Benefits paid through local authorities:
•
•
•
•
Housing Benefit
Council Tax Benefit
Free School Meals
Clothing Vouchers.
Activities
Make notes on the following measures taken to provide income for
those not employed:
•
•
•
•
Jobseeker’s Allowance
Income Support
Pension Credit
Winter Fuel Payments.
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Other initiatives to tackle social exclusion
Sure Start Scotland
Sure Start Scotland has been in operation since 1999. It provides targeted
support to families with very young children aged 0 -3 years who are, for
whatever reason, most vulnerable. The programme emphasises the importance
of joint working between local authorities, voluntary agencies, heal th services
and existing child support networks. These parties are encouraged to work
together to provide a more cohesive service to meet the need of parent and
child.
The aim of Sure Start Scotland is to promote social inclusion through a
positive start in the lives of very young children; and helping them to get the
most from subsequent opportunities including pre-school education. Sure
Start Scotland recognises that the child develops within the family, with the
wellbeing and skills of parents fundament al to a child’s progress; communitybased, family-focussed resources, including high-quality childcare and direct
support to parents, will strengthen parents’ ability to maximise their child’s
potential; and independent research indicates that the most eff ective forms of
intervention are those initiated in early infancy and that are sustained
thereafter.
Sure Start Scotland is a key element of the Scottish Executive’s social
inclusion agenda.
The objective of Sure Start Scotland is to build upon existing networks of
resources, within the local community. This may involve drop -in centres in
urban areas or mobile outreach projects in more rural areas. Local authorities,
voluntary organisations, health services and parents should all be involved in
the planning and provision of services. Provision should grow from within the
community, and should be targeted to those communities most in need.
Funding has been distributed to all local authorities in Scotland on a weighted
basis to reflect population, deprivation and rurality. Funding in 2005/06
stands at £52.9m, and is set to rise to £56.9m in 2006/07.
Sure Start Scotland funding should be used to provide an integrated package
of support for families with very young children. However, there is no
prescriptive model and support should meet the needs of the local area. A
package of support could include delivery mechanisms aimed at:
• improving children’s emotional and social development
• improving children’s health
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• improving children’s ability to learn
• strengthening families and communities.
Family Centres are a key element of the Sure Start programme in England,
but the same emphasis has not been given to them in Scotland. Whilst we do
not have specific plans in relation to children’s centres, what we are working
towards is providing comprehensive integrated services for children that
meets their individual needs when they need it. By this way of working we
are looking towards the outcomes for children. There are already children’s
centres in some areas across Scotland but it is not the most appropriate way
forward for all areas.
(Based on information from Sure Start and from the Scottish Executive
websites:
http://www.surestart.gov.uk and
http//www.scotland.gov.uk/publications/recent)
Activities
Make notes on:
•
•
the aims of Sure Start
how these aims are to be met.
Effectiveness of government policy towards pensioner poverty
Government policies to reduce pensioner poverty have made an impact. In the
three-year period 1995 to 1997, 27% of pensioners in the UK had an income
less than 60% of the median income. By 2002 –03, this had fallen to 21%. The
introduction of Pension Credit combined with house price growth has helped
to improve the financial position of today’s pensioners. However, the
Pensions Commission has said that retirement poverty may get worse in
future because today’s workers are not saving enough.
Government benefits do help many pensioners with an income but they do not
meet all pensioner needs. During the 2004 winter, 21,500 people over the age
of 65 died as a direct result of the cold in England and Wales, according to
the Office for National Statistics. Since 2000, each winter in England and
Wales, between 20,000 and 50,000 people aged 65 and over have suffered
avoidable winter deaths. The UK has a higher number of avoidable winter
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deaths than in comparable European countries. EU countries that experience
more severe winters than the UK, such as Finland and Germany, have much
lower levels of cold-related mortality.
Pensioners may be eligible for up to 23 state benefits and entitlements.
Key benefits for pensioners:
• State Retirement Pension is paid to men aged 65 and over and women aged
60 and over, subject to National Insurance contributions.
• Attendance Allowance provides financial help for severely disabled people
over the age of 65 with the extra costs of care due to the effects of
disability.
• Minimum Income Guarantee (paid as Income Support) is paid to people
over 60 and helps with basic living expenses.
• Disability Living Allowance provides help to severely disabled people
under the age of 65 with the extra costs of care due to the effects of
disability. The benefit can continue after age 65 in certain circumstances.
There is a care component for people who need help with personal care
and a mobility component for people who need help getting around.
• Housing Benefit provides help with paying the rent and some service
charges.
• Winter Fuel Payment provides pensioners with help towards the costs of
fuel bills.
• Council Tax Benefit provides help with paying council tax bills.
• Help with health costs for people aged 60 years and over includes free
NHS prescriptions and eye tests.
This is a complex system, much of which is means -tested, so many
pensioners do not claim what they are entitled to claim either through pride,
ignorance or fear. 1 in 3 pensioners fail to claim Income Support. Between a
quarter and a third of entitled pensioners do not claim the Minimum Income
Guarantee; 33% of pensioners do not claim Council Tax Benefit, and 10% of
those entitled to Housing Benefit do not claim.
Many low-income pensioners have little knowledge about the be nefits
available to them and tend to find out about them from relatives and friends,
rather than official sources. Certain groups, such as pensioners in rural areas,
those with sensory impairments such as sight, mobility or hearing, and
pensioners from ethnic minorities, face additional barriers.
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Turner Report
With pensioners living longer and the birth rate falling, governments are
becoming increasingly concerned about the country’s ability to fund state
pensions for all in the future. In 2005, people of pensionable age made up
21% of the population. By 2050, they will account for nearly 30%. The
government is concerned that the tax burden placed on a contracting
workforce by a burgeoning dependent pensioner population will become
unsustainable.
Lord Turner, the head of the Pensions Commission, was commissioned to
review the evidence and provide recommendations for the future of pension
provision in the UK. His report was published in 2005.
The Turner Report advised raising the state pension age from 65 to 68 by
2050. This would be a gradual increase in pension age – to 66 by 2030, 67 by
2040 and 68 by 2050. In return for an increase in the state pension age, the
commission said the basic state pension should in future rise in line with
earnings, rather than inflation.
The report also proposed:
• employees to be automatically enrolled into a new National Pension
Savings Scheme (NPSS) if they are not already in a sufficiently backed
company scheme, although they would have the right to opt out
• the current state second pension should evolve into a flat -rate payment
• the state system should be ‘as non means -tested as possible’
• the savings element of the pension credit should rise by less than average
earnings.
Lord Turner’s vision for the future involves people working longer, retiring
later, saving more and receiving higher pensions once they have retired. In
his plan he suggested that people could achieve a retirement pension close to
two thirds of their salary.
To achieve this he estimates that the revamped basic and second state
pensions (indexed according to average earnings rather than lower rates of
inflation, and made universal and not dependent on contributions) could
replace 30% of an average worker’s salary. The National Pension Sav ings
Scheme (NPSS), in its basic form, should add a further 15% of former
income.
Finally if people save and put even more money away to be invested in the
NPSS funds then they could add a further 15%. Add all that up and it comes
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to 60% of salary, not far short of the two-thirds target that the best
occupational schemes offer to staff who stay with their employers for 40
years.
The funds put into the NPSS will be invested in things such as shares, bonds
and property, while the ordinary state pension continues to be paid for
directly out of tax and National Insurance.
Activities
Make notes on:
• the effectiveness of recent government approaches to pensioner
poverty
• the Turner Report
• the reasons for commissioning the report
• the findings of the report.
The impact of recent government policies on poverty
(This section is adapted from ‘Changing Poverty post -1997’, by David
Piachaud and Holly Sutherland, on the Joseph Rowntree Foundation
website.)
Effects 1997 to 2000/1
Analysis of the Family Resources Survey showed that between 1996/7 and
2000/1 there was some progress with regard to children, but less progress
with regard to poverty among other groups.
The reasons for the changes in relative poverty between 1996/7 and 2000/1
are:
• unemployment fell and more households had someone in paid employment.
• policy on benefits and tax credits clearly disadvantaged some groups while
it helped others.
Those who depended on benefits found them falling relative to incomes
generally and were likely to be losers. They included those on the basic state
pension, Jobseeker’s Allowance and Incapacity Benefit, and those on Income
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Support who did not have children. Groups more likely to gain were those
with children, particularly low earners in employme nt. This was a major
factor in the reduction of the number of children in poverty by half a million.
Changes in poverty up to 2003/4
Child poverty
In 1997 between one-quarter and one-third of children – 3 to 4 million UK
children, depending on the measure of income used – were living in
households in relative poverty. This was triple the proportion in poverty in
1979.
Policy measures taken between 1997 and 2003/4 resulted in 1.3 million fewer
children being in poverty than would otherwise have been the case.
Lone parents have a high level of uptake of the new tax credits. 40% of lone parent working mothers avoid poverty because of tax credits leaving only 8%
of the low-paid lone working mothers living in household poverty.
Pensioner poverty
Pensioner poverty showed little change between 1996/7 and 2000/1 but a
substantial reduction between 2000/1 and 2003/4; the size of this reduction is
very different – between one million and a quarter of a million – depending
on whether or not housing costs are taken into account (housing costs are on
average lower for pensioners than for the rest of the population).
The impact of indirect taxes
On balance, indirect taxes and duties have increased in real terms since 1997
(though they fell between 2000/1 and 2002/ 3). This has affected poorer
households disproportionately, because indirect taxes generally represent a
higher proportion of income for those on lower incomes. Lone -parent
households have been hit hardest by the above -average increase in tobacco
duties. Pensioners have been least affected by changes in indirect taxes,
largely because those aged over 75 were exempted from TV licence fees
during this period.
What are the prospects beyond 2003/4?
For poverty to remain at the same level, let alone fall furth er, it is necessary
both for employment levels to be maintained and for benefits and tax credits
to rise in line with median incomes. This necessarily requires increasing
expenditure in real terms, although not as a proportion of national income. In
terms of overall poverty, it remains the case that Income Support levels are
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substantially below the 60% of median income poverty level used by the
government. The failure in recent years to increase these benefit levels in line
with incomes generally has made this situation worse.
Conclusion
The findings of this study show the challenge that tackling poverty
represents. Between 1996/7 and 2000/1 relative poverty fell, largely as a
result of improvements in employment rates and in the level of some benefits.
What the study shows is that greater employment, or ‘work for those who
can’, has made a real contribution to reducing poverty. But there is a limit to
how much further employment measures can contribute to reducing poverty.
The study also shows that without the improvements which have been made
to the tax and benefit system for those with low incomes, poverty would be
much worse. Changes in indirect taxation have had only a small effect on
poverty but it is important for the future that their regressive effects are taken
into account. Whatever its form, more redistribution will be needed each year
simply to maintain the progress which has been made.
In 1999 a goal was set of halving child poverty by 2010 and a relative
definition of poverty was clearly adopted. Even if this goal is achieved,
relative poverty will still be higher than in 1979. It will be possible to stay on
track to achieve this goal but to do so will require substantially more
redistribution to the poorest and continuing priority to be given to the goal of
ending child poverty. Further reductions in child poverty are likely to be
increasingly hard to achieve. The task of ending poverty more generally
remains to be tackled.
© Joseph Rowntree Foundation 2005, reproduced by permission
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Routes into and out of poverty
(Adapted from ‘Routes into and out of Poverty’, an article on the Joseph
Rowntree Foundation website.)
There is considerable persistence in poverty among some groups of people.
Those most at risk of persistent poverty are c hildren, older people, lone
parents, social housing tenants, adults with no educational qualifications, and
workless households.
In the 1990s, over a third of people on low incomes escaped from poverty
between one year and the next. Apart from education, the key ladders out of
poverty were:
•
•
•
•
paid work – moves into work or increased earnings
increases in non-labour income
changes in household composition
moves out of ill health or disability.
Labour-market events were the most common routes out of poverty, but the
importance of different routes varied from one type of household to another.
• For lone parents, the event most likely to be associated with escape from
poverty in the 1990s was acquiring a new partner, where this was
accompanied by a move into paid work.
• For couples with children, labour-market events were the most common
ladder out of poverty. Demographic events, such as changes in household
type or reductions in the number of children in the household, were much
less important.
• For older people, increases in non-benefit, non-labour income – mainly
pensions and savings – were the most common route out of poverty in the
1990s. The next most common route was improvements in mental and
physical health, mainly because of their relatively high incidence among
older people. Although very few older people were affected by labour market events, where these occurred they were associated with a very high
rate of escape from poverty.
Work as a ladder out of poverty
Paid work is the most common route out of poverty, but it is not a guaranteed
one. Just over half of adults of working age who are in poverty – 2.6 million
people – live in households where at least one person is working.
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Work is not always a route out of poverty because some jobs are low paid.
Low pay is concentrated among certain industries (such as catering, retail and
residential care) and occupations (for example, hairdressers, cleaners and
security guards). Women and young people are the most likely to be low paid.
The incidence of low pay has increased over the past quarter of a century.
For many people, low pay is not a transient experience: low -paid workers
tend to remain low paid. Low-paid jobs often do not act as stepping-stones to
better-paid ones; they are more likely to constitute dead ends from which
there is relatively little prospect of escape. Low -paid jobs also tend to be
more precarious than higher-paid ones. Indeed, there appears to be a ‘low
pay, no pay’ cycle in which periods of low pay are interspersed w ith periods
of unemployment. Being out of work appears to have a ‘scarring’ effect on
future earnings, thereby helping to perpetuate low pay. Moreover, this wage
penalty increases with length of time out of work.
The National Minimum Wage has helped to tackle the problem of low pay. It
has raised the pay of about 1.3 million workers, or about 5 –6 % of all
employees. About three-quarters of those who have benefited are women.
Despite having one of the lowest unemployment rates among the Organisation
for Economic Co-operation and Development countries, Britain also has one
of the highest rates of worklessness. Currently, about one in six working -age
households has no adult in paid employment. Since 1997, various New Deals
have been introduced to improve employability and help long-term
unemployed and economically inactive people into work. The emerging
evaluations of these programmes point to success in helping people into
unsubsidised jobs. However, these programmes have been better able to help
people who are reasonably ‘job ready’ than those who are more detached
from the labour market.
For some economically inactive people, including the most severely disabled
people, paid employment is not a realistic option and therefore not a route out
of poverty. Most of these people rely on social security benefits for their
income. For such households, improvements in social security benefits could
be the most important ladder out of poverty.
Young people
The transition from childhood to adulthood has become mor e protracted and,
for some, more fractured than in the past. Critical points in this transition can
act as ladders out of, or snakes into, poverty. For young people, ladders out
of poverty operate on three interconnected pathways: the school -to-work
transition, the domestic transition and the housing transition.
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Changes in the nature of the labour market and in family structures mean that
young people face new risks and challenges when making the transition from
education to employment. In today’s labour market there is greater demand
for a highly trained workforce, while traditional craft apprenticeship routes to
employment have declined. Most young people stay on in education or
training for longer than their predecessors did. Those who do not stay on ha ve
fewer opportunities and a more insecure outlook later on in life. Despite the
New Deal for Young People, long-term unemployment among young people
has not been eliminated, though it is at a much lower level than it was in
1997.
Young people with caring responsibilities often miss out on education, which
can later lead to unemployment and social exclusion. Young people from
certain minority ethnic backgrounds are at increased risk of lower educational
achievement and discrimination in the labour market. Young people’s family
of origin is a crucial determinant of their future success. Good family
relationships can provide a route out of poverty by enabling young people to
follow their chosen careers. For young people with a disability, their family’s
resources are crucial for a successful transfer to independent living. However,
for some of the most disadvantaged young people, a problematic family
background may be part of their difficulties.
The supply of affordable housing available to young people has f allen
because of a decline of social housing, constraints on access to privately
rented housing, and an owner-occupier sector characterised by price inflation.
Living in the parental home can soften the impact of unemployment and low paid jobs. Low-income young people who have left home often live in poor
physical conditions and need parental support.
Families with children
Changes to the child tax and benefit package since 1999 have lifted large
numbers of families with children out of poverty. The gove rnment is on
schedule to achieve its target of reducing the number of children in relative
poverty by a quarter between 1998–99 and 2004–05.
Income from paid work is the most important ladder out of poverty for
families with children, especially full-time work for lone parents. Acquiring a
new partner can be a ladder out of poverty for lone parents, particularly if the
new partner is employed. However, the high cost of childcare can be a barrier
to taking up paid work and can make people worse off in work than on
benefits. Affordable, accessible, high -quality childcare is essential for paid
work to be a more secure ladder out of poverty for lone parents.
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Income from child support (maintenance) payments can also help to make
work pay for lone parents. It can enable them to manage on lower earnings or
shorter hours or, by supplementing wages, make combining work with
looking after children a financially viable option. But child support is only an
effective ladder out of poverty for children if it increases income, is not offset by a fall in benefit, and is both regular and reliable. In addition, child
support payments to first families can act as a route into poverty for the
second families of non-resident parents.
Older people
The level of income in retirement is determined by opportunities in working
life.
A sizeable minority of older people continue to work beyond retirement age,
but the proportion doing so tails off quite quickly after five years. There is a
high rate of escape from poverty among older people who continue to work.
For most older people, investments are not a major source of income, but they
have become more important over the post -war period.
The loss of a partner can result in significant change in household income.
Where the surviving spouse does not inherit their partner’s pension income,
poverty may increase. This disproportionately affects women since they are
more likely to be both survivors and without separate pensions rights.
The level of means-tested benefit for pensioners has increased very
substantially in real terms since 1999, but a significant minority of older
people fail to claim these benefits. Improved take -up of benefits is thus a
potential ladder out of poverty for people above state retirement age.
© Joseph Rowntree Foundation 2005, reproduced by permission
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Activities
Make notes on:
•
the impact of recent government policies on
– child poverty
– tax and national insurance
•
routes into and out of poverty
– importance of work
– problems with work as a route out of poverty
– young people
– families with children
– older people.
Practice essay
Assess the effectiveness of recent government welfare policies.
(15 marks)
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Section 7
Policies to deal with health inequalities
A brief history of the founding of the welfare state
When the post-war Labour government introduced the welfare state in 1945 it
was the product of a century of struggle over how to tackle poverty.
Originally poverty was tackled by the Elizabethan Poor Law based on local
parishes. However, the industrial revolution multiplied the scale of the
problem and the Poor Law became hopelessly inadequate to deal with it.
By the early 1900s all political parties realised that only the state was
powerful enough to address the problem. In 1906, the Liberals introduced a
system but it was limited in scope, and it made little progress in tackling
poverty among people of working age. The end of the First World War was
followed by a slump, which hit industrial towns in the Scotland, Wales and
the north of England, and worsened into the Great Depression of the 1930s.
Working-class poverty caused by unemployment led to atrocious housing
conditions, widespread ill health, disease and poor education.
When the UK entered the Second World War, the p ressure for social reform
was intense. The shared sacrifice of the war encouraged the belief that ‘never
again’ should Britain fight for an unequal and unfair society. Widespread
rationing reduced consumption among the rich but actually improved the diet
of the poor. Many key social institutions, such as hospitals, were nationalised
for the duration of the war. The equality produced by nationalisation and
rationing led many to believe that a centrally led system should continue in
peacetime.
During the war, the coalition government asked William Beveridge, a Liberal
social reformer, to study the problem and create a plan. In December 1942,
despite the government’s unease, he published the Beveridge Report on
Social Insurance and Allied Services, which detailed his own comprehensive
programme of social reform ‘from the cradle to the grave’.
His system was based on a universal flat rate benefit, payable to all, on the
basis of fixed National Insurance contributions. It was to cover old age,
unemployment and sickness. Beveridge wanted to tackle what he called the
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‘five giants’ – want, disease, squalor, ignorance and idleness – through a
universal welfare state which would provide a comprehensive health service,
vastly expanded public housing, free and univers al secondary education, and
full employment, as well as benefits for the poor and family allowances.
Full employment – and the relative prosperity that went with it – was the key
to his plan and would be the responsibility of the state.
His ideas became very popular with the public, and the new Labour
government, which took power in 1945, did so on the promise that it would
implement the Beveridge Report in full as soon as possible.
However, in the post-war austerity that the UK faced, the government was
unable to afford to pay an adequate level of flat -rate benefits that would keep
people out of poverty. So, from the start, the first fundamental principle of
his system was undermined. National Assistance was means -tested and so
based on the old Poor Law. Means-testing has remained at the heart of social
insurance ever since instead of the flat-rate payment everyone would be
entitled to as envisaged by Beveridge.
Another problem was the idea that entitlement was based on National
Insurance contributions. It was intended to give people the right to their
benefits and avoid the stigma of asking for a handout. However, it meant that
many people, especially women, were excluded from the system.
Family allowances were never implemented in the generous way B everidge
intended. Child Benefit followed by Child Tax Credits did not provide the
means to remove families with dependants from poverty. Investment in
health, education and housing soon proved inadequate to meet social needs.
When the UK welfare state was created in the 1940s, it was the model
admired around the world. But in the last 50 years it has become Europe’s
poor relation. Continental systems today provide more generous welfare
benefits for their citizens without the stigma of the means test.
When it was introduced in 1948, the principles on which the NHS was based
were that the state was to take collective responsibility for a universal and
comprehensive range of services with equality of access for all.
Collective responsibility: The state took responsibility for funding a centrally
directed health service aimed at removing inequalities both in access to health
care and in the quality of health for the population.
Universal: The entire population would be entitled to the full range of health
services free at the point of need.
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Comprehensive: The NHS was to be responsible for improving the nation’s
health through education and prevention as well as for diagnosis and
treatment.
Equality: The NHS intended to create equality of health provision throughout
the regions of the UK as well as equal access irrespective of wealth.
Activities
Make notes on:
•
•
•
the aims of the post-war reforms that led to the welfare state
the shortcomings of these reforms
the main features of the welfare state.
Structure and key features of the NHS 2006
Health care in the UK is essentially split in two sectors: primary care and
secondary care.
Primary care is usually the first point of contact most people have with the
NHS and is delivered by a wide range of professionals, including family GPs,
nurses, dentists, pharmacists and opticians. This care focuses on the treatment
of routine injuries and illnesses as well as preventive care, such as services to
help people stop smoking.
Primary care is mostly concerned with a patient’s general health needs, but
increasingly more specialist treatments and services are being made by
primary care providers in clinics closer to where people live.
Secondary care is also called acute care. It can be by referral by a prima ry
health professional such as a GP. Sometimes called elective care, it is
planned specialist medical care or surgery – for example a hip replacement
operation or kidney dialysis. It usually takes place in an NHS hospital where
a patient may be admitted either as an inpatient or a day case patient, or
where they may attend for an outpatient consultation or clinic.
Accident and Emergency (A&E) care is when patients attend hospital as a
result of an accident or trauma and require emergency treatment. Some
patients will come to A&E themselves and others will arrive in an ambulance.
Examples of emergency care include responses to a sudden onset of chest
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pain or a road traffic accident. Patients using A&E will be seen, treated and
discharged – or admitted to a ward for further care.
Other examples of secondary care services include specialist services for
mental health, learning disability and older people.
Structure of NHS provision in England and Wales
England and Wales: NHS structure
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The Department of Health
The aim of the Department of Health is to improve the health and well -being
of people in England. It sets the standards and broad working practices of the
NHS and local social services. It sets the overall strategic direction of the
NHS, sets national standards to improve quality of services and prioritises
areas such as cancer, coronary heart disease and mental health. It provides the
funds from government spending to ensure the NHS and social care are able
to deliver services.
Strategic Health Authorities (SHAs)
There are 28 SHAs covering England and they are the key link between the
NHS and the Department of Health. SHAs are responsible for managing and
setting the strategic direction of the NHS locally. They monitor how well
Primary Care Trusts and NHS Trusts (hospitals) are performing in their area
and take action to improve services when they are poor or failing. They
develop plans for improving health services locally. They make sure national
priorities are fully reflected in local healt h service plans.
Primary Care Trusts (PCTs)
PCTs are central to NHS delivery and control 80% of the total NHS budget.
They are responsible for assessing the health needs of all the people in their
local area and commissioning the right services to meet th ese needs from GP
practices, hospitals and dentists.
They have duty to improve the overall health of the local population. They
must make sure that services can be accessed by everyone who needs them
and must listen to patients’ views on services and act on them. They have to
carry out annual assessments of GP practices in their area.
They report directly to their local Strategic Health Authority. As well as
buying and monitoring services, they also help local GP practices, NHS
Trusts and other parts of the NHS think about how they deliver better care to
the communities they serve.
Primary care delivery:
• GP practices diagnose and treat a wide range of health problems in the
local community. Doctors usually work with a team including nurses,
health visitors and midwives, as well as a range of other health
professionals such as physiotherapists and occupational therapists.
Practices run clinics, give vaccinations and carry out simple surgical
operations. They also offer health education and advice on thi ngs like
smoking and diet.
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• Every UK citizen has a right to be registered with a local GP and visits to
the surgery are free.
• Dentists mainly work in dental practices and provide check -ups and
treatments such as fillings, extractions, as well as scal ing and polishing.
Part of their work involves advising people on how to look after their teeth
and gums. Dental practices take private and NHS patients with many being
a mixture of both.
• Pharmacists (chemists) supply prescription and ‘over-the-counter’
medicines and health care advice to patients and members of the public.
• Opticians carry out eye and sight tests, prescribe and fit spectacles.
• NHS Walk-in Centres provide fast ‘no-appointment’ advice and
treatments for minor conditions. There are n ow 66 Walk-in Centres
throughout England, often situated near A&E and in convenient locations
such as high streets and train stations. They are run by experienced NHS
nurses who provide treatment for minor illnesses including coughs, colds
and infections and for minor injuries such as cuts, sprains and strains as
well as advice on how to stay healthy.
• NHS Direct is a confidential nurse-led health advice service over the
phone 24 hours a day, 365 days a year. The lines are staffed by nurses and
professional advisors.
Secondary care delivery:
• Hospitals provide secondary care for both emergency and planned
treatment. Except in the case of emergencies, hospital treatment is
arranged through a GP. This is called a referral. Appointments and
treatment at NHS hospitals are free. Hospitals provide a wide variety of
services from consultants, doctors, nurses, hospital dentists, pharmacists,
midwives and health visitors, physiotherapists, radiographers, podiatrists,
speech and language therapists, dieticians, counsellors, occupational
therapists and psychologists.
• NHS Foundation Trusts are a new type of NHS hospital run by local
managers, staff and members of the public. Hospitals with a record of high
performance can apply to become NHS Foundation Trusts. It is a status
which gives them much more freedom in running their services than other
NHS Trusts. The intention behind introducing Foundation Trusts is to shift
power over decision-making to frontline staff and the local communities
they serve. Foundation Trusts remain part of the NHS.
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• Ambulance Trusts are the local organisations responsible for responding
to 999 calls and transporting patients. They respond to life -threatening and
urgent conditions such as heart attacks and road accidents. Depending on
the nature of the emergency a rapid response vehicle, crewed by a
paramedic and equipped to provide treatment may be dispatched.
Ambulance staff assess patients at the scene and decide whether they need
to go to hospital.
(Adapted from Department of Health website:
http://www.nhs.uk/england/AboutTheNhs/Default.cmsx )
Structure of NHS provision in Scotland
In 2001, 15 Unified Health Boards (12 mainland and 3 island) replaced 43
NHS Trusts and Health Boards in Scotland. They are responsible for all
health services in their area.
In 2005, the number of Health Boards in Scotland was reduced from 15 to 14
when the Scottish Executive announced that the Argyll and Clyde Health
Board was to be scrapped. The board, which serves 420,000 people in an area
stretching from Campbeltown to Paisley, was £80 million in debt. Ministers
decided there was no prospect of balancing the books and the debt was
written off. The board’s responsibilities wer e divided between NHS Greater
Glasgow and NHS Highland.
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Scotland: NHS structure
How the system works
• The Scottish Executive sets strategic objectives and national priorities for
the NHS as a whole.
• The SEHD monitors local health systems through regular performance
returns and the Performance Assessment Framework.
• Annual accountability review meetings are held between the SEHD and
each NHS board to discuss and agree past performance and future
priorities.
• NHS boards prepare local health plans annually. NHS boards publish
annual reports on their activities and performance.
• Most NHS boards have based their operating divisions on acute and
primary care services.
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• Community Health Partnerships (CHPs) bring together primary care
professionals and planning partners (e.g. local authorities) to coordinate
the planning, development and provision of the community health services
for their area or district. They will evolve from Local Health Care
Cooperatives (LHCCs), which were voluntary groups o f GP practices, with
input from others working in primary care. In 2004, there were 80 LHCCs
of varying sizes serving different parts of Scotland. It is intended that
these will be reduced to between 40 and 50 when CHPs get under way
properly. For example the plan for NHS Greater Glasgow intends that the
16 LHCCs should evolve into eight or possibly nine CHPs, each serving
populations of 90,000+.
• Hospitals continue to be run by Trusts. However,Trust Boards have been
replaced by Trust Management Teams.
• Golden Jubilee National Hospital. Scotland’s largest private hospital,
called Health Care International, was bought for £37.5 million by the
government in 2002, to help reduce waiting times for treatment. It was
intended for use as a national resource and not as part of the provision for
Glasgow and the West of Scotland. Originally designated the National
Waiting Times Centre, it is run separately as one of the Special Health
Boards.
Activities
Make notes on:
• the structure of the NHS in England and Wales
– Primary Care Trusts and how they deliver health care
– hospitals
– Foundation Hospitals
– Ambulance Trusts
• the structure of the NHS in Scotland
– Unified Health Boards
– Special Health Boards
– Community Health partnerships
– Hospital Trusts
– Golden Jubilee National Hospital.
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Private Medical Insurance (PMI)
PMI is designed to help towards the cost of private treatments for curable,
short-term illness or injury. It enables people to receive prompt treatment
from a specialist of their choice at a private hospital at a time convenient to
them.
Premiums are based on a number of factors, including age, gender, state of
health and pre-existing medical conditions, among others. The premiums
increase as the policy holder gets older or if they make an insurance claim for
treatment. Medical insurance also excludes chronic conditions that require
permanent or prolonged treatment, or routine dental treatment and cosmetic
surgery, except when required following a disfiguring illness or an accid ent.
PMI excludes cover for ‘pre-existing’ conditions. For example, if someone
has a history of heart disease then cardiac surgery would be excluded. Cancer
patients with private health insurance discover that their policies fail to cover
them for the full course of their treatment. Vital therapies are excluded from
the cover such as chemotherapy and certain breast cancer treatments.
The cost of the insurance is high, averaging about £1,000 per year, and it
increases as a person gets older. Increases in long-term care premiums are
forcing many elderly people to abandon plans despite having already poured
thousands of pounds into them. In 1993, when she was 71, Cambridge
resident Rosemary Thompson signed up to a £36.76 a month plan from A XA
PPP. It was meant to provide her with £100 a week if she needed care. She
paid in £36.76 a month for 11 years. In 2004 A XA PPP told her to choose
between increasing the monthly premium to £64 or face a benefit cut to £75 a
week. As she was on a fixed income she could no t afford the extra premium
so was forced to write off all the money she had invested.
In 2005, the elderly could be charged as much as £2,000 –£3,000 a year, even
for basic private medical insurance cover. Even a healthy 40 -year-old male
with no dependants will be charged £500–£750 a year for PMI with
restrictions around the amount of out -patient care offered. A luxury plan with
no restrictions will cost a 40-year-old in London more than £1,500 a year.
The Labour government is opposed to offering tax incen tives for private
medical insurance. Labour ended tax relief on private medical insurance when
it came to power. The Conservatives want to see the private sector expand
both by making the NHS buy more private care and by encouraging a greater
take-up of private health insurance.
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There are several private insurers providing health insurance such as AXA
PPP, BUPA, Norwich Union and Standard Life. The cost of premiums is high
to cover administration costs, the cost of private operations and the profits of
the private health care providers. Some examples of the cost of private
operations are:
•
•
•
•
•
•
•
•
Cataract removal £1,800–£3,000
Coronary artery bypass graft £13,500–£17,500
Cruciate ligament repair £3,750–£4,800
Epidural injection £650–£1,000
Hip replacement £7,200–£10,000
Vasectomy £300–£900
Vasectomy reversal £1,000–£2,200
Wisdom teeth extraction £1,100–£1,400
Table: The extent of Private Medical Insurance cover in the UK
1992
2002
6.67 million
6.71 million
Company paid schemes
4.15 million
4.71 million
Personal sector schemes
2.51 million
2.00 million
Value of UK market
£1.5 billion
£2.9 billion
Claims of UK market
£1.2 billion
£2.2 billion
Persons covered by PMI
PMI providers
Source: Adapted from Laing and Buisson’s Private Medical Insurance UK Market
Report 2003
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Activities
Make notes on:
•
•
•
•
•
•
Private Medical Insurance
what it covers
how much it costs
examples of treatment costs
extent of PMI in the UK
attitude of the Labour government to PMI.
Private hospitals
Private health care provided an estimated £15 billion in health services in
2001. There are about 230 independent hospitals. More than half of them run
by the three main providers – General Health Care Group, BUPA and
Nuffield Hospitals.
The private sector performs about 20% of all non -urgent surgery, one-third of
all hip replacements and almost half of all abortions. There are also about
3,000 ‘pay beds’ in the NHS, about half of which are in dedicated private
patient units.
Private medical insurance accounts for 75% of the income in the private
sector with 20% from direct payments by patients and about 5% from
treatment funded by the NHS.
Scotland
Scotland has nine private hospitals, with a total of 900 beds available for
patients who pay for their health care. These include Murrayfield Hospital in
Edinburgh, Ross Hall and Nuffield in Glasgow, Abbey Carrick Glen in Ayr,
Abbey King’s Park in Stirling, Fernbrae in Dundee and Albyn in Aberdeen.
In 2002 the Scottish Executive block-booked spare beds in Scotland’s private
hospitals at a cost of £4 million in a bid to cut waiting lists. Around 500
patients who had been waiting for up to a year for a hip or knee replacements
had their operations carried out in private hospitals around Scotland.
In June 2002, in a bid to cut waiting times the Scottish Executive bought the
former Health Care International (HCI) private hospital in Clydebank for
£37.5 million. HCI was originally renamed the National Waiting Times
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Centre and eventually the Golden Jubilee National Hospital. The Executive
said it would help cut waiting times across Scotland for cardiac conditions
and for those seeking hip and knee replacements, cataract surgery, general
surgery, plastic surgery and diagnostics.
However, private hospitals in Scotland continue to enjoy major increases in
business because of the increase in NHS waiting lists. In 2004, in-patient and
day-case waiting lists between March and June increased by 4,215 to 86,549.
As a result some private hospitals in Scotland had a 40% rise in the number
of people opting to spend thousands of pounds on their treatment in order to
jump the queues. In 2005 some private hospitals reported a continued
increase of up to 25% in private patients. The number of Scots buyi ng private
medical insurance increased by 60% between 2002 to 2005 and self -paying
patients now account for at least 21% of all non -NHS treatment.
These trends indicate the public’s concern over continuing increases in
waiting lists. Patients with painful non-urgent conditions such as hernias,
varicose veins, cataracts and hip and knee replacements are paying for their
own care to avoid the long and often painful wait for free treatment on the
NHS. Over 7,400 patients out of 34,150 who were admitted for in patient or
day patient treatment at Scotland’s acute private hospitals in 2004 paid out of
their own pockets.
The official number of patients who have been diagnosed but are still
awaiting hospital treatment has grown by 1,590 to 113,612 in a year. Scott ish
outpatients are also forced to wait longer than outpatients in England. Only
64% of patients in Scotland are treated within 13 weeks as opposed to 70% in
England.
In 2000, the Labour government made an agreement with the private sector
that ended 50 years of hostility between the party and private hospitals. The
government sees a role for private hospitals in easing the traditional NHS
problems with capacity during the winter, and in reducing waiting times and
lists. Private providers were already performing about 40,000 procedures a
year for the NHS, and there has been a three - to four-fold increase in NHSfunded activity since the agreement was signed. However, there are still
concerns that a major expansion of the private health market would mean a
contraction of the public sector because both sectors rely on the same pool of
staff.
The private sector provides most of the residential provision for elderly and
physically disabled people and, with almost 70 independent mental health
hospitals, more than half the health service’s medium-secure places for
seriously mentally ill patients are now provided independently.
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Activities
Make notes on:
• the extent and growth of private health care in the UK and Scotland
• the Labour government’s attitude to private health care.
Practice essay
Critically examine the impact of the private health sector in recent
years.
(15 marks)
Public Private Partnership (PPP)
The PPP, also known as the Private Finance Initiative (PFI), is a way of using
private-sector finance to build hospitals. It largely replaces the system which
has worked well for the last 50 years, in which new hospitals have been paid
for directly by public money.
Under a PPP, a private-sector consortium pays for a new hospital. The local
NHS Trust pays the consortium a regular fee for the use of the hospital,
which covers construction costs, the rent of the building and the cost of
support services. This means that most new NHS hospitals will be designed,
built, owned and run by a consortium or group of companies. A consortium
usually consists of a construction company, a bank or financier, a facilities
management contractor and consultants.
To date, the Labour government has approved 15 acute hospital PPP schemes
in England. Three hospital PPP schemes are also underway in Scotland. The
appeal of PPPs for the government is that the cost of the hospital does not
appear as an immediate lump sum payment in public expenditure.
The NHS will employ some of the staff – mainly doctors and nurses – and
will rent the building and other facilities from the consortium for at least 25
years. Most of the staff including the domestics, catering, porters, security
and maintenance staff will be employed by a private contractor. Quite
possibly the receptionists, secretaries and laboratory technicians will also be
employed by the contractor.
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PPP hospitals have a private wing or even a separate private hospital next
door. Equipment and facilities are shared between NHS and private patients.
New PPP hospitals have fewer beds than the services they replace.
The medical care will remain free but even within the public part of the
hospital there will be a growing introduction of charges, perhaps presented as
optional extras. If you want better food or more privacy th en you will have to
pay for it.
Benefits of PPP
• The government can have new hospitals built in the short term without
having to raise the finance and passing the cost on by increasing current
tax rates or by reducing other spending.
Arguments against PPP
• The additional costs of funding PPP hospitals are passed on to future
taxpayers who are bound to pay the charges. To pay for the building work,
the private companies borrow the money from banks at higher rates of
interest than government-funded schemes. The private companies aim to
make a profit on the scheme which means they will go for cheap options,
which are likely to reduce the quality of care.
• The contracts setting up PPP hospitals are not made public because it is
claimed it would interfere with ‘commercial confidentiality’. However, as
there is little or no competition for these contracts, the profits on
investment can be highly inflated. Few know the profit to be made on
these PPP contracts but two recent PPP ventures (not linked with
hosptials) have been bought out and may give some indication of the
inflated profits to be gained by the private investors.
The Skye Bridge, built in 1995, cost £15 million and in the seven years it
was run by the Skye Bridge company the company earned £50 m illion: £23
million from the tolls and £27million from the Scottish Executive buyout.
Similarly the Inverness Airport Terminal Building cost £9 million to build.
The company was paid £8.5 million in rent in six years and then the
contract was bought out for £25 million. In both cases the companies’
return on their original investment was extremely high in less than 10
years. The capital value of the PPP hospital in Norfolk and Norwich is
£214 million. If similar levels of profit are made on this project the n over
the next 25 years the taxpayer could be charged over £1 billion for the
facility.
• PPP schemes are undemocratic. Firstly, the costs are not disclosed so the
public is denied the right to express its views on this issue at an election or
elsewhere. Secondly, these agreements put influence over the health
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service into private hands, and Hospital Management Teams become junior
partners in the running of hospitals. It means that future improvements in
NHS hospitals will be influenced by commercial c onsiderations rather than
on the basis of health.
• Staff employed by the PPP hospitals will find their jobs, pay and
conditions squeezed to achieve ‘efficiency savings’ for the Trust and to
boost profits for the consortia. The experience of the past 10 years of
competitive tendering suggests that most of those who lose out will be
women, who make up 72% of NHS support staff. NHS policies on equal
opportunities for staff, health and safety at work, or promoting a healthy
hospital environment will be under threat in the interests of efficiency and
profit. Poorer employment conditions for those working for PFI consortia
will reduce morale, teams will not work effectively and the quality of the
service will fall.
Compulsory competitive tendering
‘Patients perceive a major deterioration in the cleanliness of hospitals since
the introduction of Compulsory Competitive Tendering.’ (Source: The NHS
Plan – A plan for investment – A plan for reform – 2000.)
In 1983, the Conservative government introduced compulsor y competitive
tendering for domestic, catering and laundry services in the NHS. All NHS
organisations had to put those services out to tender and the cheapest bid
always won the contract. To keep costs down, contractors cut wages and
conditions and reduced cleaning hours.
In cleaning, 90% of the costs are staffing. In 1986, there were 67,000 full time domestics working in the NHS. In 2005 there were around 36,000
domestic staff employed – almost half the number. Low staffing levels put
pressure on staff, which has resulted in low morale, higher rates of sickness
leave and problems in recruitment and retention.
During the same period there was an enormous increase in MRSA in hospitals
throughout the UK. MRSA is resistant to many types of antibiotics and is
usually caught while in hospital. It can be fatal. The main defence against
MRSA is through cleanliness, including adequate cleaning of hospitals.
Unfortunately, compulsory competitive tendering led to a deterioration in
hospital cleaning and the NHS is now faced with spiralling numbers of
hospital-acquired infections, which cost the NHS more than £1 billion to treat
and claim at least 5,000 lives every year.
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Activities
Make notes on:
• Public Private Partnerships
– how they work
– arguments for
– arguments against
• compulsory competitive tendering
– how it works
– its impact on the NHS.
Practice essay
Critically examine the impact of the private sector in the NHS.
(15 marks)
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RESOURCES
Resources
Useful websites
BBC Front Page website: http://news.bbc.co.uk
Scottish Executive website: http://www.scotland.gov.uk
Social Exclusion Unit: http://www.socialexclusionunit.gov.uk/
Joseph Rowntree Foundation: http://www.jrf.org.uk/
Department of Work and Pensions: http://www.dwp.gov.uk/
Public Health Institute of Scotland: http://www.phis.org.uk/
One Parent Families Scotland: http://www.opfs.org.uk/
New Deal: http://www.newdeal.gov.uk/
Department of Health: http://www.dh.gov.uk/PublicationsAndStatistics/fs/en
NHS Scotland: http://www.healthscotland.com/
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