Bratain the country and its people: an intruduction for learners of english James O’Driscoll Oxford Contents

18 WELFARE

The most straightforward way in which people are helped is by direct payments of government money. Any adult who cannot find paid work, or any family whose total income is not enough for its basic needs, is entitled to financial help. This help comes in various ways and is usually paid by the Department of Social Security.

Anyone below the retirement age of sixty-five who has previously worked for a certain minimum period of time can receive unemployment benefit (known colloquially as ‘the dole’). This is organized by the Department of Employment.

All retired people are entitled to the standard old-age pension, provided that they have paid their national insurance contributions for most of their working lives. After a certain age, even people who are still earning can receive their pension (though at a slightly reduced rate). Pensions account for the greatest proportion of the money which the government spends on benefits.

The government pension, however, is not very high. Many people therefore make arrangements during their working lives to have some additional form of income after they retire. They may, for instance, contribute to a pension fund (also called a ‘superannuation scheme’). These are usually organized by employers and both employer and employee make regular contributions to them. A life insurance policy can also be used as a form of saving. A lump sum is paid out by the insurance company at around the age of retirement.

Some people are entitled to neither pension nor unemployment benefit (because they have not previously worked for long enough or because they have been unemployed for a long time). These people can apply for income support (previously called supplementary benefit) and if they have no significant savings, they will receive it. Income support is also sometimes paid to those with paid work but who need extra money, for instance because they have a particularly large family or because their earnings are especially low.

► The origins of the welfare state in Britain

Before the twentieth century, welfare was considered to be the responsibility of local communities. The ‘care’ provided was often very poor. An especially hated institution in the nineteenth century was the workhouse, where the old, the sick, the mentally handicapped and orphans were sent. People were often treated very harshly in work- houses, or given as virtual slaves to equally harsh employers.

During the first half of the twentieth century a number of welfare benefits were introduced. These were a small old-age pension scheme (1908), partial sickness and unemployment insurance (1912) and unemployment benefits conditional on regular contributions and proof of need (1934). The real impetus for the welfare state came in 1942 from a government commission, headed by William Beveridge, and its report on ‘social insurance and allied services’. In 1948 the National Health Act turned the report’s recommendations into law and the National Health Service was set up.

The mass rush for free treatment caused the government health bill to swell enormously. In response to this, the first payment within the NHS (a small fixed charge for medicines) was introduced in 1951. Other charges (such as that for dental treatment in 1952) followed.

A wide range of other benefits exist. For example, child benefit is a small weekly payment for each child, usually paid direct to mothers. Other examples are housing benefit (distributed by the local authority, to help with rent payments), sickness benefit, maternity benefit and death grants (to cover funeral expenses).

The system, of course, has its imperfections. On the one hand, there are people who are entitled to various benefits but who do not receive them. They may not understand the complicated system and not know what they are entitled to, or they may be too proud to apply. Unlike pensions and unemployment benefit, claiming income support involves subjecting oneself to a ‘means test’. This is an official investigation into a person’s financial circumstances which some people feel is too much of an invasion of their privacy. On the other hand, there are people who have realized that they can have a higher income (through claiming the dole and other benefits) when not working than they can when they are employed.

The whole social security system is coming under increasing pressure because of the rising numbers of both unemployed people and pensioners. It is believed that if everybody actually claimed the benefits to which they are entitled, the system would reach breaking point. It has long been a principle of the system that most benefits are available to everybody who qualifies for them. You don’t have to be poor in order to receive your pension or your dole money or your child benefit. It is argued by some people that this blanket distribution of benefits should be modified and that only those people who really need them should get them. However, this brings up the possibility of constant means tests for millions of households, which is a very unpopular idea (and would in itself be very expensive to administer).

► The language of benefits

With the gradually increasing level of unemployment in the last quarter of the twentieth century, many aspects of unemployed life have become well-known in society at large. Receiving unemployment benefit is known as being ‘on the dole’ and the money itself is often referred to as ‘dole money’. In order to get this money, people have to regularly present their UB40s (the name of the government form on which their lack of employment is recorded) at the local social security office and ‘sign on’ (to prove that they don’t have work). They will then get (either directly or through the post) a cheque which they can cash at a post office. This cheque is often referred to as a ‘giro’.

Social services and charities

As well as giving financial help, the government also takes a more active role in looking after people’s welfare. Services are run either directly or indirectly (through ‘contracting out’ to private companies) by local government. Examples are the building and running of old people’s homes and the provision of‘home helps’ for people who are disabled.

Professional social workers have the task of identifying and helping members of the community in need. These include the old, the mentally handicapped and children suffering from neglect or from maltreatment. Social workers do a great deal of valuable work. But their task is often a thankless one. For example, they are often blamed for not acting to protect children from violent parents. But they are also sometimes blamed for exactly the opposite - for taking children away from their families unnecessarily. There seems to be a conflict of values in modern Britain. On the one hand, there is the traditional respect for privacy and the importance placed by successive governments on ‘family values’; on the other hand, there is the modern expectation that public agencies will intervene in people’s private lives and their legal ability to do so.

Before the welfare state was established and the concept of‘social services’ came into being, the poor and needy in Britain turned to the many charitable organizations for help. These organizations were (and still are) staffed mostly by unpaid volunteers, especially women, and relied (and still do rely) on voluntary contributions from the public. There are more than I £0,000 registered charities in the country today. Taken together, they have an income of more than £ I £ billion. Most of them are charities only in the legal sense (they are non-profit-making and so do not pay income tax) and have never had any relevance to the poor and needy. However, there are still today a large number which offer help to large sections of the public in various ways (► Some well-known charities).

Charities and the social services departments of local authorities sometimes co-operate. One example is the ‘meals-on-wheels’ system, whereby food is cooked by local government staff and then distributed by volunteers to the homes of people who cannot cook for themselves. Another example is the Citizens Advice Bureau (CAB), which has a network of offices throughout the country offering free information and advice. The CAB is funded by local authorities and the Department of Trade and Industry, but the offices are staffed by volunteers.

► Some well-known charities

The NHS (the national health service is commonly referred to by this abbreviation) is generally regarded as the jewel in the crown of the welfare state. Interestingly, it is very ‘un-British’ in the uniformity and comprehensiveness of its organization. When it was set up it did not, as was done in so many other areas of British public life, accommodate itself to what had already come into existence. Instead of entering into a partnership with the hundreds of existing hospitals run by charities, it simply took most of them over. The system is organized centrally and there is little interaction with the private sector. For instance, there is no working together with health insurance companies and so there is no choice for the public regarding which health insurance scheme they join. Medical insurance is organized by the government and is compulsory.

However, in another respect the NHS is very typically British. This is in its avoidance of bureaucracy. The system, from the public’s point of view, is beautifully simple. There are no forms to fill in and no payments to be made which are later refunded. All that anybody has to do to be assured the full benefits of the system is to register with a local NHS doctor. Most doctors in the country are General Practitioners (GPs) and they are at the heart of the system. A visit to the GP is the first step towards getting any kind of treatment. The ► GP then arranges for whatever tests, surgery, specialist consultation or medicine are considered necessary. Only if it is an emergency or if the patient is away from home can treatment be obtained in some other way.

As in most other European countries, the exceptions to free medical care are teeth and eyes. Even here, large numbers of people (for example, children) do not have to pay and patients pay less than the real cost of dental treatment because it is subsidized.

The modern difficulties of the NHS are the same as those faced by equivalent systems in other countries. The potential of medical treatment has increased so dramatically, and the number of old people needing medical care has grown so large, that costs have rocketed.

The NHS employs well over a million people, making it the largest single employer in the country. Medical practitioners frequently have to decide which patients should get the limited resources available and which will have to wait, possibly to die as a result.

In the last few decades, the British government has implemented reforms in an attempt to make the NHS more cost-efficient.

One of these is that hospitals have to use external companies for duties such as cooking and cleaning if the cost is lower this way.

Another is that hospitals can ‘opt out’ of local authority control and become self-governing ‘trusts’ (i.e. registered charities). Similarly,

GPs who have more than a certain number of patients on their books can choose to control their own budgets. Together these two reforms mean that some GPs now ‘shop around’ for the best-value treatment for their patients among various hospitals.

These changes have led to fears that commercial considerations will take precedence over medical ones and that the NHS system is being broken down in favour of private health care. And certainly, although pride and confidence in the NHS is still fairly strong, it is decreasing. There has been a steady rise in the number of people paying for private medical insurance (► Private medical care) in addition to the state insurance contribution which, by law, all employed people must pay.

In fact, though, Britain’s health system can already claim cost- efficiency. The country spends less money per person on health care than any other country in the western world. One possible reason for this is the way that GPs are paid. The money which they get from the government does not depend on the number of consultations they perform. Instead, it depends on the number of registered patients they have - they get a ‘capitation’ allowance for each one. Therefore, they have no incentive to arrange more consultations than are necessary. It is in their interest that their patients remain as healthy as possible and come to see them as little as possible, so that they can have more patients on their books. The other possible reason is the British ‘stiff upper lip’. In general, people do not like to make a big drama out of being ill. If the doctor tells them that there is nothing to worry about, they are likely to accept this diagnosis. Partly as a result of this, British GPs prescribe significantly less medicine for their patients than doctors in other countries in Europe do.

When it was set up, the NHS was intended to take the financial hardship out of sickness - to offer people medical insurance ‘from the womb to the tomb’. In this respect, despite the introduction of charges for some kinds of treatment, it can still claim to be largely successful.

► Private medical care

The medical profession

Doctors generally have the same very high status in Britain that they have throughout the world. Specialist doctors have greater prestige than ordinary GPs, with hospital consultants ranking highest. These specialists are allowed to work part-time for the NHS and spend the rest of their time earning big fees from private patients. Some have a surgery in Harley Street in London, conventionally the sign that a doctor is one of the best. However, the difference in status between specialists and ordinary GPs is not as marked as it is in most other countries. At medical school, it is not automatically assumed that a brilliant student will become a specialist. GPs are not in any way regarded as second-class. The idea of the family doctor with personal knowledge of the circumstances of his or her patients was established in the days when only rich people could afford to pay for the services of a doctor. But the NHS capitation system (see above) has encouraged this idea to spread to the population as a whole.

Most GPs work in a ‘group practice’. That is, they work in the same building as several other GPs. This allows them to share facilities such as waiting rooms and receptionists. Each patient is registered with just one doctor in the practice, but this system means that, when his or her doctor is unavailable, the patient can be seen by one of the doctor’s colleagues.

The status of nurses in Britain may be traced to their origins in the nineteenth century. The Victorian reformer Florence Nightingale became a national heroine for her organization of nursing and hospital facilities during the Crimean War in the 18£OS. Because of her, nurses have an almost saintly image in the minds of the British public, being widely admired for their caring work. However, this image suggests that they are doing their work out of the goodness of their hearts rather than to earn a living wage. As a result, the nursing profession has always been rather badly paid and there is a very high turnover of nursing staff. Most nurses, the vast majority of whom are still women, give up their jobs after only a few years. The style of the British nursing profession can also be traced back to its origins. Born at a time of war, it is distinctively military in its uniforms, its clear- cut separation of ranks, its insistence on rigid procedural rules and its tendency to place a high value on group loyalty.

► Nurses uniforms

► The emergency services

► Alternative medicine

1 In Britain, the only people who can choose whether or not to pay national insurance contributions are the self-employed. More and more of them are choosing not to do so. Why do you think this is?

2 Would you say that the balance in Britain between welfare provided by the state and welfare offered by charities is different from that in your country? In Britain, does the balance appear to be a stable one, or is it shifting in favour of one or the other? Is the same true in your country?

3 From your reading of this chapter do you think that the British welfare state is successful in giving help to everybody who needs it? How many and what kinds of people do you think ‘slip through the net’ of care?

4 What, according to this chapter, are the main problems of the welfare state in modern Britain? Are similar problems encountered in your country? What solutions have been suggested or tried in Britain? Do you think they are the right ones?

5 How does the general status and public image of nurses in Britain compare with that of nurses in your country?