The official figures which appear to show a widening of class differences in health in England and Wales during the post-war period have been controversial partly because they do not fit with common perceptions of what has happened to differences in the standard of living. As a result, a great deal of effort has gone into investigating suggested weaknesses in the decennial social class mortality data. Though initially plausible, the artifactual and selective explanations of the widening mortality differences which were put forward have not usually been borne out by closer investigations. The only fault in the broad picture presented by the official data which we do perhaps need to bear in mind is the tendency for a narrowing of mortality differentials among younger women to be masked by the widening among older women. This paper is an attempt to look at the other side of the coin--namely, to investigate trends in differences in the standard of living in relation to mortality differentials. It concludes that trends in mortality differences have not been related to trends in class differences in average earnings, but have been fairly clearly related to trends in relative poverty. Relative poverty and class differences in mortality declined before the war but have both increased, decade by decade, since the war. Younger women have perhaps been protected from the increase in relative poverty during much of the post-war period by their increased economic activity rates and the relative improvement in earnings of women in poorly paid manual occupations.
This paper examines the dynamics of scandal creation and control involved in the public expos é of conditions and ill treatment at the public mental asylum of Prestwich , Lancashire in 1921. It identifies the groups and interests involved in orchestrating the public and official responses which culminated in a departmental committee of inquiry. It focuses particularly upon the conflicts and divisions within the bureaucratic institutions of the Board of Control, the Ministry of Health and the local asylum authorities, and argues that the Prestwich expos é was used in a strategy which established increased ministerial control of mental health services.
The BMA (British Medical Association)-TUC (Trades Union Congress) Joint Committee on Medical Questions, established in 1936, was an experiment in consensus. It was the first attempt to cross the barriers in medical politics. In the 1930s the strategy of 'administration rather than advocacy' prompted the co-operation of the TUC with the BMA on medical questions of mutual interest. The operation of the partnership is explored here in the formulation of a scheme for a national maternity service acceptable to both parties. However, the reality of co-operation at the level of specific proposals was an insistence by the BMA on its own point of view. The TUC had to decide whether a joint scheme was worth the price. Although a scheme was eventually produced, as an experiment in consensus the committee had failed. To some extent the war obscured this failure, but the consensus itself was wrecked by the intransigence of the BMA and the hostility of the Labour movement, which was angry at the extent of the concessions which the TUC had made for a national maternity scheme.
This article, in which we examine developments in public expenditure on social policy in relation to total public spending in the United Kingdom (UK) in the period after the Second World War, is part of a larger international study on developments in social welfare spending on which we are currently engaged. In Section 1 we briefly sketch in the theoretical background to the study of public expenditure growth in general and social welfare spending iompeting hypotheses - this exercise is in hand as part of the international study, and we shall report the finding at a later date. Section 2 examines the growth of public expenditure in the UK at the aggregate level. In Section 3 we analyse public expenditure at the individual programme level and in Section 4 we summarize the conclusions.
Since the election of the Thatcher Government in 1979, public expenditure on the welfare state has undergone a series of changes. The nature of change has, however, often been obscured by the use of inadequate and misleading statistical data. This paper presents a systematic examination of public expenditure on education, health care, housing and social security over the period 1979/80 to 1984/85. It shows that, contrary to much political rhetoric, the major changes in the welfare state have not always arisen from reductions in programme expenditures, but from changes in the composition of expenditure. It is the latter that has often increased economic inequality and can be legitimately referred to as 'restructuring'.
This paper examines the extent to which low household income influences access to primary health care in both the US and the UK. The basic approach is to ask whether, given data about a person's age, sex, and self-reported general health status and history, extra information about whether or not they come from a low-income household adds a statistically significant amount to the probability of their obtaining various amounts of primary medical care. The measure of primary medical care is derived from the number of physician visits and it, along with the other data, is drawn from the 1977 US National Medical Care Expenditure Survey and the 1980 UK General Household Survey. Although the two surveys cover different sample periods, they are similar enough to make comparisons between the two countries possible. The main conclusion drawn from the study is that low household income is not an important determinant of the actual use of primary health care resources. Only with subgroups of the low-income population (UK women and US relatively unhealthy individuals) does there appear to be a statistically significant effect, which is quite small in comparison to other factors.
The problem over the use of accident and emergency departments is portrayed in terms of a typical conflict between professional and lay needs. However, in contrast with the more common image of the professional hospital doctor successfully developing both structural and interactional strategies for maintaining professional dominance over the patient, it is argued that the structural characteristics of the accident and emergency department pose control problems for the profession. These control problems have been exacerbated by developments in other areas of the health service and have led to the development of policies which emphasize both clinical and social elements of patient need. Although there is apparent recognition by providers of the importance of taking into account patient need, the proposed policies are based on professional images of how patients 'ought' to use the service. What is clearly lacking is comprehensive data on how the public and the community wishes to use the service and how they actually use the service. Data from national and local studies on patient felt needs and patient demand for the hospital accident and emergency departments are presented and the implications for policy are discussed.
The idea that the happiness and wellbeing of individuals should shape government policy has been around since the enlightenment; today such thinking has growing practical policy relevance as governments around the world survey their populations in an effort to design social policies that promote wellbeing. In this article, we consider the social determinants of subjective wellbeing in the UK and draw lessons for social policy. Survey data are taken from the 'Measuring National Wellbeing Programme' launched by the UK's Office for National Statistics in 2010. For the empirical strategy, we develop bivariate and multivariate logistic regression models, as well as testing for interaction effects in the data. The findings show that wellbeing is not evenly distributed within the UK. Socio-demographic characteristics such as age, gender, ethnicity, employment, household composition and tenure all matter, as does health status. Influencing population wellbeing is inherently complex, though, that said, there is a clear need to place greater emphasis on the social, given the direction of current policy.
President Ronald Reagan brought a new circus to town in 1981. He billed it as offering never-before-seen, awe-inspiring acts of skill and daring, with demand-side management by ‘rational expectations monetarists’ and supply-side engineering by ‘new economists’, the performers in the centre ring would tame inflation and usher in permanent growth. Others would increase defence expenditures while cutting taxes and balancing the budget all at one and the same time without hurting the ‘truly needy’ or weakening the legitimate ‘safety nets’ of the ‘merely seedy’. The grand finale would bring forth the problem-saving capacities of states and localities as well as private philanthropies, all of which had been ‘crowded out’, according to Reagan, by an overspending, overtaxing, over-regulating, problem-causing federal government, which had been the featured performer in previous, not very successful ‘great shows’ in Washington.
Carers occupy an ambiguous position within the social care system. Services are predominantly structured around the dependent rather than the carer, and this has important consequences for their delivery and evaluation. Many of the problems that arise in thinking about carer issues relate to confusion over the way the relationship between social care agencies and informal carers should be perceived. The paper outlines three models that provide frames of reference for this relationship: carers as resources; carers as co-workers; and carers as co-clients. The tensions between these are then used to explore the contradictions of policy in this field.
The approved societies, who were charged with the administration of health insurance in Britain, have long been blamed for the failure of the scheme to expand its coverage or scope in the interwar period. This paper takes a closer look at the administrative process and argues that societies were more vulnerable to central regulation than is commonly thought and were unable to resist cuts in public subsidies and extensions in liability introduced at their expense. They provided a convenient scapegoat for policies emanating primarily from the economic orthodoxy subscribed to by both government and the Treasury, modified to protect the unemployed during the slump. Health insurance policy was dominated to a large extent by the Government Actuary, who aimed to guarantee the cost effectiveness of the scheme. This paper also shows how administrative definitions and practices affected the classification of claimants to state social insurance at this time. It re-establishes the major weaknesses of the system, arguing that--in the light of recent discussions about reviving a system of national health insurance--we have much to learn from looking again at the experience of the interwar period.
The core of this paper is a case study of how a District Health Authority (Paddington and North Kensington, now Parkside DHA following a recent merger with Brent DHA) in Inner London responded to a major new health care issue of the 1980s--Aids, but the paper also seeks to locate this case study material within wider debates. What theories are there of organisational change which could be used to illuminate policy and service change in the health care sector? How, indeed, do we best study change in health care organisations? The paper is thus in three parts. In the first section we identify some streams of literature which act as a frame of reference defining our initial research question and discuss implications for methodology. The second section presents the case itself, while the last section discusses some emerging findings.
This paper investigates two issues of equity in the receipt of the home help service, one about territorial justice, the other about sex discrimination. It uses GHS data for 1980. An argument is developed about the efficiency with which services are targeted on persons who by normative criteria would appear to have most need of them. Efficiency is of two types: horizontal efficiency, the proportion of persons judged in need who receive services; and vertical efficiency, the proportion of services allocated to persons judged in need. The findings are that there is evidence of inequity both between different areas and between the sexes. Metropolitan areas are advantaged compared with rural areas, and this cannot be explained by differences in social support nor by the availability of other domiciliary services. Among the elderly living alone, neither sex is advantaged, but in elderly married couple households the home help service is more frequently provided in the case of a husband caring for a disabled wife than in the case of a wife caring for a disabled husband.
The objective of this article is to analyse the way in which budget allocation decisions have been made in the National Health Service (NHS) of Britain. Despite the criticisms of the pre-1948 health care system on the grounds of geographical inequity, it was not until nearly twenty-five years after the service's inception that explicit allocation formulae were devised and implemented in an attempt to achieve equity, defined as equal financial resources for health care for those in equal need.
The article is divided into four sections; the first analyses briefly the establishment of the NHS in 1948 and the failure of policy-makers to rectify the significant inequalities in the distribution of health care inputs between the regions. The second section is concerned with the official recognition of the policy problem of geographical inequality in resources and the first attempt to rectify it. In the third section the most recent set of resource allocation formulae for England, Scotland and Wales will be analysed and compared. The final section offers some brief conclusions.
This paper examines the current model of sheltered housing and explores a central contradiction in that model: namely that if only those people who most need and appreciate the unique features of sheltered housing were allocated places in schemes, the existing model ultimately could not provide sufficient support. This central contradiction leads to a fundamental lack of clarity in the role of sheltered housing. This is reflected in the ambiguities apparent in allocation practices, where judgements are typically made not only in relation to the tenants' needs and demands but also in relation to the impact on schemes. Evidence is presented from a recent study of sheltered and amenity housing in Scotland, which exposes these issues and suggestions are made as to how the traditional model of sheltered housing can be made more flexible and more suited to those who need and value it most.
The setting of health priorities is primarily concerned with the equitable distribution of resources and is now more than ever an important part of strategic planning within the National Health Service (NHS). The basic information which can be used to assist in such decision-making and the process by which different agencies become involved are important aspects of priority-setting; this article is based on a major review of the research literature on these aspects and provides a discussion and an analysis of experience within health and other fields. From this material a number of possible approaches to priority-setting are identified and discussed. The article concludes that, before it can be decided how priorities should be set in the future, outstanding questions about how far rational approaches are feasible, about who is to be involved and what role they should play, and about how far such decisions are to be taken nationally or locally will need further consideration.
It is widely recognised that there are many problems with the community care policy for the mentally ill which has been in operation in England and Wales since the late 1950s. However, many existing accounts of the development of the policy rest upon a variety of erroneous assumptions about how it has evolved, and which in turn affect our understanding of how it might be changed. Some of these assumptions are examined, and it is argued that frequently they fail to acknowledge how both the rhetoric and the reality of the policy have developed. Taking this critique into account, a more accurate assessment of how to understand community care for the mentally ill is offered.
This paper provides a case study of the involvement of carers in planning services for mentally handicapped people under the All Wales Strategy (AWS). After describing the structure for consumer participation in the AWS in Gwynedd, reasons for the low level of participation found are examined before considering what can be learnt from these early experiences. Major changes in the planning structure implemented after a review of the system are outlined. The paper ends with a discussion of the major operational principles which might underlie an effective system of consumer participation.
Using voluntary blood donation as a case example, the study on which this article is based explored not only the extent, or breadth, of community involvement in social policy behaviours, but also the continuity, or depth, of this commitment. Demographic and motivational data were collected through a postal questionnaire returned by 1,784 persons who had voluntarily donated blood at least once in metropolitan Toronto between 1974 and 1978. An empirical distinction was also drawn between the ‘active’ and the ‘lapsed’ donor.
The study found that while certain sectors of society were probably disproportionately represented among those who chose to undertake voluntary social behaviours, the continuity of these actions could not be statistically associated with demographic or socio-economic variables. However, it did find that donors initially motivated by ‘external’ considerations such as convenience of location were more likely to lapse, while those for whom moral considerations and a sense of community were most important were more likely to continue as active donors.
The general conclusion suggests that manipulating the context may be useful to broaden the initial participatory base in voluntary actions, but to produce continuity in this involvement the challenge must be phrased in moral language.
The issue of housing and health has received growing attention in recent years. This article reviews why this has been the case and presents the results of the authors' study of housing and health in two areas of West Belfast. A large scale household survey was carried out in Divis Flats and part of the Twinbrook estate, both deprived areas of public sector housing, to compare health and housing conditions. The health of children in Divis is shown to be much worse than the health of children in Twinbrook. Respiratory conditions, diarrhoea, vomiting and psychological distress were particularly common. The health of adults in Divis was also markedly worse than in Twinbrook, and the health of women generally worse than men. The authors conclude that Divis Flats is a contemporary public sector slum and support the case for clearance and rehousing. However, it is argued that the health problems of Divis are one, extreme, manifestation of a wider problem of ill health in low income, 'mass housing' areas.
This article presents an historical overview of the changing meaning of the patient-consumer, and specifically the role played by patient groups in constructing the patient as consumer. It is argued that patient groups were central to the formation of the patient-consumer, but as health consumerism was taken on by the state, they lost control of this figure. Competing understandings of what it meant to be a patient-consumer developed, a shift that raises further questions about the unity of claims made in the name of the patient-consumer.
This paper discusses issues raised by the uneven expansion of private health care in Britain in recent years. The problems being experienced by the industry have exposed divisions in the private health care industry and have provoked criticisms of the Government and requests for a greater degree of state support for, and regulation of, the industry. The paper therefore examines the scope for changes of government policy to facilitate further expansion. It argues that few of the alternatives are either technically adequate, in terms of solving the private sector's problems, or politically feasible, in the sense of being electorally justifiable. It concludes that policies to further private sector expansion could be implemented only at the cost of the private sector's independence, or at the expense of the Government's commitment to the NHS.
The article discusses the evolution of Newfoundland's health care system from the turn of the century to the present. During this time there were considerable changes in social conditions, political arrangements and the availability of public monies, all of which influenced the structure of the health care sector. In general terms, Newfoundland's health care system shifted from one involving low expenditures and many British type institutions to one involving high expenditures and American type institutions. The evidence suggests that the changes have been particularly beneficial for Newfoundland's merchant class, including the doctors and dentists, although some benefits have also accrued to patients and fishermen.
This paper examines the proposition that the welfare policies enacted and legitimized in the name of 'choice' have the effect of increasing the effective choice of service by consumers of welfare. The example of residential care of the elderly is used to illustrate the ways in which privatisation has influenced choices of care for elderly people in Devon. The paper reviews empirical material from two survey of private homes in Devon in order to throw light on the 'myths' and realities of choice in residential accommodation and in other welfare provision available to the elderly in Devon. The paper identifies as the key debate the question of priorities: whether resources should be concentrated on providing suitable residential places for the increasing number of the very disabled elderly or used to increase the alternatives for the larger, more able groups. The latter option can perhaps be reasonably achieved through market mechanisms, whilst the former is more likely to require the specialised skills of social workers and other caring professionals. Although it is possible to argue that the growth in numbers of private old people's homes represents an increase in choice for the elderly, on closer examination this appears too simple an assertion. The expansion of the private sector has not necessarily expanded the range of alternative forms of care. In particular, there seems a major flaw in current policies by which the operation of the DHSS subsidy increases the availability of residential rather than domiciliary care.
Frequent increases in the real value of National Health Service (NHS) patient charges have been made since the Conservative Party's return to office in 1979. For those patients subject to these charges the increases have led to a substantial reduction in the level of subsidization of the cost of the service. The rationale for the subsidization of health care is shown to be unrelated to 'ability to pay' considerations. Consequently the 'backdoor privatization' of these services is inconsistent with the objectives of the NHS even though the Government has continually committed itself to these objectives. Alternative policies to increasing patient charges are suggested which would encourage the efficient use of NHS resources without compromising NHS objectives.
It is often argued that there are significant differences in the costs of providing public and non-public services. However, these arguments have almost invariably been based on crude comparisons of bald expenditure figures of rather dubious validity. In this paper we describe and apply a conceptual framework which attempts to place such inter-sectoral comparisons on a more reliable basis. Our application is to day care services for elderly people provided by local authority social services departments, area health authorities and voluntary organizations, although the framework has much wider relevance. Our results provide clear evidence to refute the oft-made assumption that voluntary services are universally cheaper than their statutory counterparts. Standardizing costs for the dependency characteristics of users and the activities of day units, we find that voluntary-statutory cost differences are dependent upon the scale of operation. Small voluntary units certainly enjoy a cost advantage, but larger voluntary units are unlikely to be cheaper, and are probably more expensive, than local authority units of a similar scale.
In the United Kingdom a range of services for elderly people in the community has developed that is delivered by a variety of professionals and administered within different organisations. This has resulted in a problem of co-ordinating services to meet the individual needs of the most frail elderly people. In the United States 'case management' has been introduced as a way of improving the co-ordination of care. Despite structural differences in the provision of health and social services between the United States and the United Kingdom, the concept of case management has influenced the design of a number of innovatory schemes in the United Kingdom, including the Gloucester Care for Elderly People at Home project (CEPH). These innovatory schemes have demonstrated the need for a 'keyworker' and clarified the tasks that are involved in taking responsibility for co-ordinating services to meet the needs of elderly people at risk of failing to cope at home. There is, however, a danger of proliferating the complexity of service provision by creating a new breed of professional; an alternative might be to alter the responsibilities, attitudes and team orientation of existing professional workers so as to include taking on the keyworker role for some of their clients.
Within both publicly and privately financed health care systems different funding mechanisms have evolved, or have been proposed, to deal with the problem of 'moral hazard'. Moral hazard arises when financial incentives within the health care system lead to either inefficient demands for care by consumers or inefficient supply of care by providers. In this paper the problem of moral hazard is outlined in more detail, and different ways of countering moral hazard are reviewed in terms of three criteria: effect on patient utilisation of health services in general: effect on utilisation by different groups of patients; and effect on health status. It is concluded that evidence on different methods of funding health services can only be judged in the context of objectives. If the objectives of health care delivery are 'maintenance or improvement of health' and 'equal access for equal need' then charges of finance of care through health maintenance organisations both appear to be less favourable than 'free' care at the point of delivery whilst the latter is not necessarily more costly as a result. Research on other suggested alternatives is required, otherwise radical changes to health care financing in the UK will simply result in movement from one unproven system to another.
All social services are rationed, yet the effects of such rationing on the client are rarely fully explored. This article reviews the evidence on the existence of informal rationing devices in general practice. It examines the effects on patients of a wide range of informal rationing devices now used by individual general practitioners. Various suggestions for reforming the present rationing of primary medical care are evaluated and the likelihood of any reform being carried out is assessed. Although this article concentrates solely on rationing in the primary care sector of the National Health Service, the issues discussed are relevant to most welfare agencies as they are presently organized.
Although community care has been the professed policy of successive governments over three decades, according to the Prime Minister's own adviser, Sir Roy Griffiths, 'in few areas can the gap between political rhetoric and policy on the one hand or between policy and reality in the field on the other hand have been so great'. This paper examines the extent and causes of this 'implementation gap' in respect of services for people with mental handicaps--a consistent priority group for national policymakers. We examine centre-periphery relations in the health and personal social services in the light of Rhodes' power-dependence framework and his concepts of policy networks and policy communities. The NHS has been described as the archetypal professionalised policy network but we conclude that it is possible to account for implementation failures in community care only partly in terms of the dominance of the medical professions' values and interests and the deficiencies of accountability and control due to clinical autonomy. Such failures are due also to the inherently limited power of the centre. Sub-central units are not merely its meek agents. Moreover, the centre must explicitly structure local environments by itself providing a coherent framework of service and resource policies compatible with the national objectives it is seeking to achieve.
Travellers, or Gypsies, constitute a minority group with its own culture and traditions for whom access to health care can pose problems. A study of Traveller women and children showed that the sites where they lived were often lacking in facilities and provided a poor environment in terms of cleanliness and safety. Perinatal mortality was above average, and was especially high on sites with inadequate facilities and among the more mobile families. Immunisation and preventive care of children were both inadequate, especially among the more mobile. There continues to be a need for more, and better, permanent sites for Travellers. Other responses include allowing Traveller families to carry their own medical records, providing mobile clinics for Gypsy sites, and appointing specialist health visitors to ensure that Travellers get the heath care to which they are entitled.
Consideration of the income and social security needs of informal carers has remained conspicuously absent from discussions about 'community care'. Similarly, carers have been more or less invisible in the development of social security policies. This paper reports on a study of the financial circumstances of a sample of working age carers, who were living with and providing substantial amounts of help and support to a disabled person in the same household. The study highlights first, the substantial work-related costs incurred by carers with full time employment; and second the financial dependency of carers without full time earnings, on their spouse, sibling or on the person being cared for. The implications of these findings are discussed in the light of recent developments in social security policies.
The discussion of health inequalities in Britain (e.g. in the Black Report) has been conducted largely on the basis of social class mortality differentials measured by achieved social class and not by social class of origin. It is shown in this paper that social class mortality differentials by achieved social class are not invariant to the rate of social mobility and that the use of them is likely to result in a biased measure of trends in health inequalities when the absolute rate of social mobility varies over time. It is further shown that if, as is likely, health status is a factor systematically affecting the probability for an individual of upward or downward social mobility, then an increase in the rate of social mobility may well result in constant or widening social class mortality differentials by achieved social class even if the differentials are narrowing when measured by social class of origin. It is claimed that this process may well explain why the observed social class mortality differentials, which are measured by achieved social class, have not fallen in Britain during the post-1945 period.
During the second half of the 1970s, the practice of the closed shop became widespread in some parts of the British public sector, but was resisted in others. This paper examines the issue in relation to the National Health Service, where trade unionists made frequent demands for the closed shop and where many managers were apparently not unwilling to concede it. Yet very few closed shops actually resulted. The paper examines the origin and patterns of these demands, health authority policies towards them, and their outcomes in terms both of the operation of the closed shops which were agreed, and the reasons for failure to agree. The conclusion is that although NHS industrial relations had apparently matured very rapidly between 1973 and 1977, the trade unions were neither strong enough nor united enough to enforce the closed shop; nor were industrial relations so far developed as to make the practice a natural next step.
There has been growing academic and practitioner interest in the problems of and opportunities for joint working in the care of mentally handicapped people. The paper outlines alternative methods of such joint working and tests these against survey and case study evidence. Attention is drawn to the danger that joint working may have little impact at patient level and the paper recommends an emphasis on the appointment of frontline key workers.
This article adopts a case study approach to examine the contribution of social science research to health policy. It concentrates exclusively on the recent Royal Commission on the National Health Service. After describing its background and modus operandi the paper goes on to assess the Report's utilization of social science research, both in its diagnosis and recommendations. This assessment suggests that while the Commissioners made relatively little use of research-based evidence in their diagnosis, their recommendations provide the basis for a substantial increase in the contribution of social scientists, particularly in the field of health services evaluation.
Forecasts suggest that unemployment will remain above 2 million in Britain for the best part of the 1980s. The social consequences of protracted high levels of unemployment are explored. The evidence comes from four types of source: cross-sectional surveys of (unemployed) individuals; longitudinal and cohort studies; aggregate time series; and area-based studies. The advantages and limitations of each are identified. The available evidence on the consequences of unemployment for poverty; health and mortality; mental health; crime and delinquency; and the social fabric is reviewed. The implications for policy and public expenditure are explored.
It has never been easy to conduct research into currently sensitive policy issues, but there is now accumulating evidence to indicate that various forms of resistance to scholarly investigation are on the increase. Such a climate handicaps all social policy research, but may have the greatest impact on ethnographic projects. Yet, it is argued, ethnography is increasingly widely recognised among academics as having a particularly valuable contribution to make to the study of the policy process. Unfortunately, many policy practitioners (and occasionally some academic colleagues) perceive ethnographic research as being of questionable validity and low helpfulness. This behaves policy-oriented ethnographers to demonstrate that they do indeed have procedures for assuring validity, even if their style of investigation is never likely to be popular with government.
This article is an attempt to create a general theoretical model or ‘scale’ for categorizing voluntary organizations chiefly concerned with social service provision. Consumer participation, which the author believes has positive and particular advantages in voluntary organizations, is taken as one element in the categorization. He discusses what participation may or should mean, and the reasons why it is so rarely found. Where it exists it tends to involve the participation of staff rather than ‘clients’, which may result in more discussion than action. The article also discusses how an organization's position on the ‘scale’ can change. Voluntary organizations which start out as small, highly-participating, self-help organizations tend to become more elitist and altruistic with success and growth. The author suggests that organizations with a higher degree of consumer participation may be more responsive to social change and its consequences, more flexible and even more cost-effective than more traditionally organized institutions and may also be better able to take advantage of the independence afforded only to voluntary organizations in an increasingly state-dominated society.
A comparison of costs to the organization of alternative forms of care requires estimates for similar types of client. The degree of dependency is the main characteristic in which comparability is necessary with regard to services for the aged. This paper presents estimates of the costs incurred in providing residential care for clients of four degrees of incapacity for self-care – the capacity implicit in Bevan's residential hotel model of the old people's home, and three progressively more severe states of dependency. The estimates are for two cost concepts – average (unit) costs and marginal costs (the cost of caring for an additional person). The paper also estimates both long-run costs (costs that it is appropriate to take into account in decisions in which capital investment in new plant is being considered), and short-run costs (costs that it is appropriate to consider when the issue is the allocation of existing capacity between client groups). It also examines the consequences of the size of the home with regard to costs. Inter alia the paper shows:
(a) that the size of home beyond which costs do not fall with scale provides for as many as fifty places (equivalent to an average daily census of forty-six residents); and
(b) that, although the dependency components of costs are much smaller than the hotel components, dependency costs are large enough for it to be important to base comparisons of alternative forms of care on estimates of costs for clients which are comparable with respect to dependency.
The statutory function of local health councils in Scotland (and of community health councils in England and Wales) is to represent the interests of the public in the health service. This article, based on data from a four-year research project financed by the Scottish Office, examines official and participants' assumptions and claims about the legitimacy of health councils, as at present constituted, to carry out this function. Clarification of the basis of their legitimacy would assist, it is argued, in the resolution of a central dilemma: How are councils to represent the interests of the public? The conclusion is reached that inadequate thought was given to developing theoretically sustainable arrangements. Several interpretations of representation are admixed in the rationale for the present system and they cannot be aggregated to produce a coherent defence of it.
This paper examines the historical context of the policy decision of the (then) DHSS in July 1974 to establish Regional Secure Units with an initial provision for 1,000 places. A brief examination of the history of the detention of the criminally insane and the setting up of the county asylums is followed by an examination of the various problems faced by the authorities concerned with the care of the criminally insane and the mentally ill in general in the 1960s. The paper examines the different streams of influence and power that converged upon this solution: government, special hospitals, public inquiries, unlocking of hospital wards, criminal law, DHSS and the Home Office, judges, voluntary bodies, prisons, psychiatrists and the official government reports known as the Glancy and the Butler Reports. The paper seeks to explain the policy decision to build regional secure units as a dynamic outcome arising from the confluence of opportunities, participants and solutions: a policy formation model put forward by March and Olsen (1976).
In social policy research the gender dimension has been relatively neglected in Britain. The attempt to selectively reduce public spending is examined with reference to its objective impact on men and women using official statistics and specialist reports. In addition, on the basis of a large-scale interview survey the subjective impact of and political reactions to the cuts are analysed by gender. The main findings are that this current social policy negatively affects women as both public sector workers and consumers more than men. Political reactions to the cuts were extensive but unrelated to gender per se. However, when one controls for economic activity and related variables, gender differences in terms of both political attitudes and behaviour were insignificant compared to the contrast between the economically active and inactive. The main social policy implication is that the restructuring of the welfare state hits women first and foremost.
There has been an ongoing dispute about inequalities in health ever since the suppressed publication of the Black Report in 1980. It has recently been given a new edge by three publications: the proceedings of an SSRC Workshop held in November 1983 and the Registrar General's Decennial Supplement for 1979-1983, and another half-suppressed report, this time from Health Education Council. The first and third broadly claim that inequalities in health are widening; the second that they are irrelevant. This paper reviews the debate since 1980 around the issues of measurement (how to assess differences between social groups and how to compare across time) and the four kinds of explanation examined by the Black Report. The concluding discussion emphasises the essentially political nature of the debate over the 'trends' but concludes that, whilst most agree on the importance of materialist/structuralist variables, there are differences in the policy implications of the different explanatory positions. However, on the whole these will not be resolved by 'further research': the time is long overdue for a redistribution of resources to eradicate poverty.
Many social workers today are critical of what they regard as their profession's conventional concern with remedial social welfare. This criticism has been voiced with special reference to developing countries, and some social workers have suggested alternative roles for social work in the third world. Among these it has been suggested that social workers should take prime responsibility for social development planning in the developing countries. But this suggestion is unrealistic. Social workers are not likely to be asked to participate in national social policy formulation and planning until they have legitimized their claim to professional status and public recognition and demonstrated their ability to deal with the pressing problems of poverty in the third world through direct service.
Following its recent reorganisation of the management of the hospital sector of the NHS, the Government is currently engaged in a review of the primary health care sector. Certain of its proposals may be interpreted as suggesting movement towards a system modelled on American-style Health Maintenance Organizations (HMOs). This article seeks to explore the context in which HMOs have developed, to assess their current performance and to evaluate their potential impact on the health delivery system. It suggests that they must be understood primarily in the context of initiatives aimed at reducing health expenditure, and finds that the cost advantages claimed for them are achieved through reduced utilization rather than through greater efficiency. It also argues that this reduced utilisation is likely to increase inequalities in health care.